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_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	mrx_tier_ira_rstd_coins_1m	mrx_tier_ira_rstd_coins_2m	mrx_tier_ira_rstd_coins_3m	mrx_tier_ira_rspfd_coins_1m	mrx_tier_ira_rspfd_coins_2m	mrx_tier_ira_rspfd_coins_3m	mrx_tier_ira_mostd_coins_1m	mrx_tier_ira_mostd_coins_2m	mrx_tier_ira_mostd_coins_3m	mrx_tier_ira_mopfd_coins_1m	mrx_tier_ira_mopfd_coins_2m	mrx_tier_ira_mopfd_coins_3m	mrx_tier_ira_oonp_coins_1m	mrx_tier_ira_oonp_coins_othnum	mrx_tier_ira_ltcp_coins_1m
H0028	007	0	1	01	01	H0028_007_0	5		N	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	0		0				25		25	0		0	0		0
H0028	007	0	1	01	01	H0028_007_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	0		0				25		25	0		0	0		0
H0028	007	0	1	01	01	H0028_007_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	007	0	1	01	01	H0028_007_0	5		N	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	25		25				25		25	25		25	25		25
H0028	007	0	1	01	01	H0028_007_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	25						25			25			25		25
H0028	014	0	1	01	01	H0028_014_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	0		0				25		25	0		0	0		0
H0028	014	0	1	01	01	H0028_014_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	014	0	1	01	01	H0028_014_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	25		25				25		25	25		25	25		25
H0028	014	0	1	01	01	H0028_014_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	25		25				25		25	25		25	25		25
H0028	014	0	1	01	01	H0028_014_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	25						25			25			25		25
H0028	015	0	1	02	01	H0028_015_0	5		N	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	0		0				25		25	0		0	0		0
H0028	015	0	1	02	01	H0028_015_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	0		0				25		25	0		0	0		0
H0028	015	0	1	02	01	H0028_015_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	015	0	1	02	01	H0028_015_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	015	0	1	02	01	H0028_015_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	25						25			25			25		25
H0028	016	0	1	02	01	H0028_016_0	2			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	0		0				25		25	0		0	0		0
H0028	016	0	1	02	01	H0028_016_0	2			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	25		25				25		25	25		0	25		25
H0028	016	0	1	02	01	H0028_016_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H0028	016	0	1	02	01	H0028_016_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				69.00	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	25		25				25		25	25		25	25		25
H0028	016	0	1	02	01	H0028_016_0	2			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	25						25			25			25		25
H0028	017	0	1	01	01	H0028_017_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	0		0				25		25	0		0	0		0
H0028	017	0	1	01	01	H0028_017_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	017	0	1	01	01	H0028_017_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	25		25				25		25	25		25	25		25
H0028	017	0	1	01	01	H0028_017_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				69.00	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	25		25				25		25	25		25	25		25
H0028	017	0	1	01	01	H0028_017_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	25						25			25			25		25
H0028	019	0	1	01	01	H0028_019_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	0		0				25		25	0		0	0		0
H0028	019	0	1	01	01	H0028_019_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	25		25				25		25	25		0	25		25
H0028	019	0	1	01	01	H0028_019_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	25		25				25		25	25		25	25		25
H0028	019	0	1	01	01	H0028_019_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H0028	019	0	1	01	01	H0028_019_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	25						25			25			25		25
H0028	021	0	1	01	01	H0028_021_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	0		0				25		25	0		0	0		0
H0028	021	0	1	01	01	H0028_021_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	25		25				25		25	25		0	25		25
H0028	021	0	1	01	01	H0028_021_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	25		25				25		25	25		25	25		25
H0028	021	0	1	01	01	H0028_021_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	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	25		25				25		25	25		25	25		25
H0028	021	0	1	01	01	H0028_021_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	25						25			25			25		25
H0028	024	0	1	01	01	H0028_024_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	0		0				25		25	0		0	0		0
H0028	024	0	1	01	01	H0028_024_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	0		0				25		25	0		0	0		0
H0028	024	0	1	01	01	H0028_024_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	25		25				25		25	25		25	25		25
H0028	024	0	1	01	01	H0028_024_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	25		25				25		25	25		25	25		25
H0028	024	0	1	01	01	H0028_024_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	25						25			25			25		25
H0028	028	0	1	01	01	H0028_028_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	0		0				25		25	0		0	0		0
H0028	028	0	1	01	01	H0028_028_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	25		25				25		25	25		0	25		25
H0028	028	0	1	01	01	H0028_028_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		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	25		25				25		25	25		25	25		25
H0028	028	0	1	01	01	H0028_028_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	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	25		25				25		25	25		25	25		25
H0028	028	0	1	01	01	H0028_028_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	25						25			25			25		25
H0028	029	0	1	01	01	H0028_029_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	0		0				25		25	0		0	0		0
H0028	029	0	1	01	01	H0028_029_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	0		0				25		25	0		0	0		0
H0028	029	0	1	01	01	H0028_029_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		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	25		25				25		25	25		25	25		25
H0028	029	0	1	01	01	H0028_029_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	029	0	1	01	01	H0028_029_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	25						25			25			25		25
H0028	030	0	1	01	01	H0028_030_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	0		0				25		25	0		0	0		0
H0028	030	0	1	01	01	H0028_030_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	0		0				25		25	0		0	0		0
H0028	030	0	1	01	01	H0028_030_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		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	25		25				25		25	25		25	25		25
H0028	030	0	1	01	01	H0028_030_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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	25		25				25		25	25		25	25		25
H0028	030	0	1	01	01	H0028_030_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	25						25			25			25		25
H0028	032	0	1	01	01	H0028_032_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	0		0				25		25	0		0	0		0
H0028	032	0	1	01	01	H0028_032_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	0		0				25		25	0		0	0		0
H0028	032	0	1	01	01	H0028_032_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	032	0	1	01	01	H0028_032_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	032	0	1	01	01	H0028_032_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	25						25			25			25		25
H0028	035	0	1	01	01	H0028_035_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	0		0				25		25	0		0	0		0
H0028	035	0	1	01	01	H0028_035_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	0		0				25		25	0		0	0		0
H0028	035	0	1	01	01	H0028_035_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	25		25				25		25	25		25	25		25
H0028	035	0	1	01	01	H0028_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	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	25		25				25		25	25		25	25		25
H0028	035	0	1	01	01	H0028_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	25						25			25			25		25
H0028	036	0	1	01	01	H0028_036_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	0		0				25		25	0		0	0		0
H0028	036	0	1	01	01	H0028_036_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	0		0				25		25	0		0	0		0
H0028	036	0	1	01	01	H0028_036_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	036	0	1	01	01	H0028_036_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	036	0	1	01	01	H0028_036_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	25						25			25			25		25
H0028	037	0	1	01	01	H0028_037_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	0		0				25		25	0		0	0		0
H0028	037	0	1	01	01	H0028_037_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	0		0				25		25	0		0	0		0
H0028	037	0	1	01	01	H0028_037_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		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	25		25				25		25	25		25	25		25
H0028	037	0	1	01	01	H0028_037_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	25		25				25		25	25		25	25		25
H0028	037	0	1	01	01	H0028_037_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
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				76.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H0028	041	0	1	01	01	H0028_041_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	0		0				25		25	0		0	0		0
H0028	041	0	1	01	01	H0028_041_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	041	0	1	01	01	H0028_041_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	041	0	1	01	01	H0028_041_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H0028	041	0	1	01	01	H0028_041_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	25						25			25			25		25
H0028	042	0	1	01	01	H0028_042_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	0		0				25		25	0		0	0		0
H0028	042	0	1	01	01	H0028_042_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	042	0	1	01	01	H0028_042_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	25		25				25		25	25		25	25		25
H0028	042	0	1	01	01	H0028_042_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	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	25		25				25		25	25		25	25		25
H0028	042	0	1	01	01	H0028_042_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	25						25			25			25		25
H0028	043	1	1	01	01	H0028_043_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	0		0				25		25	0		0	0		0
H0028	043	1	1	01	01	H0028_043_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	043	1	1	01	01	H0028_043_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		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	25		25				25		25	25		25	25		25
H0028	043	1	1	01	01	H0028_043_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	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	25		25				25		25	25		25	25		25
H0028	043	1	1	01	01	H0028_043_1	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	25						25			25			25		25
H0028	043	2	1	01	01	H0028_043_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	0		0				25		25	0		0	0		0
H0028	043	2	1	01	01	H0028_043_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	043	2	1	01	01	H0028_043_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		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	25		25				25		25	25		25	25		25
H0028	043	2	1	01	01	H0028_043_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	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	25		25				25		25	25		25	25		25
H0028	043	2	1	01	01	H0028_043_2	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	25						25			25			25		25
H0028	046	0	1	01	01	H0028_046_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	0		0				25		25	0		0	0		0
H0028	046	0	1	01	01	H0028_046_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	0		0				25		25	0		0	0		0
H0028	046	0	1	01	01	H0028_046_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		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	25		25				25		25	25		25	25		25
H0028	046	0	1	01	01	H0028_046_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	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	25		25				25		25	25		25	25		25
H0028	046	0	1	01	01	H0028_046_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	25						25			25			25		25
H0028	051	0	1	01	01	H0028_051_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	0		0				25		25	0		0	0		0
H0028	051	0	1	01	01	H0028_051_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	25		25				25		25	25		0	25		25
H0028	051	0	1	01	01	H0028_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		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	051	0	1	01	01	H0028_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H0028	051	0	1	01	01	H0028_051_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	0		0				0		0	0		0	0		0
H0028	053	1	1	01	01	H0028_053_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	0		0				25		25	0		0	0		0
H0028	053	1	1	01	01	H0028_053_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	053	1	1	01	01	H0028_053_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	25		25				25		25	25		25	25		25
H0028	053	1	1	01	01	H0028_053_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H0028	053	1	1	01	01	H0028_053_1	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	25						25			25			25		25
H0028	053	3	1	01	01	H0028_053_3	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	0		0				25		25	0		0	0		0
H0028	053	3	1	01	01	H0028_053_3	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	053	3	1	01	01	H0028_053_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	25		25				25		25	25		25	25		25
H0028	053	3	1	01	01	H0028_053_3	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H0028	053	3	1	01	01	H0028_053_3	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	25						25			25			25		25
H0028	054	1	1	02	01	H0028_054_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	0		0				25		25	0		0	0		0
H0028	054	1	1	02	01	H0028_054_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	054	1	1	02	01	H0028_054_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	25		25				25		25	25		25	25		25
H0028	054	1	1	02	01	H0028_054_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H0028	054	1	1	02	01	H0028_054_1	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	25						25			25			25		25
H0028	054	2	1	02	01	H0028_054_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	0		0				25		25	0		0	0		0
H0028	054	2	1	02	01	H0028_054_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	054	2	1	02	01	H0028_054_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	25		25				25		25	25		25	25		25
H0028	054	2	1	02	01	H0028_054_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H0028	054	2	1	02	01	H0028_054_2	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	25						25			25			25		25
H0028	055	0	1	02	01	H0028_055_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	055	0	1	02	01	H0028_055_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	25		25				25		25	25		0	25		25
H0028	055	0	1	02	01	H0028_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	055	0	1	02	01	H0028_055_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				54.00	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	25		25				25		25	25		25	25		25
H0028	055	0	1	02	01	H0028_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0028	055	0	1	02	01	H0028_055_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	0		0				0		0	0		0	0		0
H0028	056	0	1	02	01	H0028_056_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	056	0	1	02	01	H0028_056_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	25		25				25		25	25		0	25		25
H0028	056	0	1	02	01	H0028_056_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	056	0	1	02	01	H0028_056_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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	25		25				25		25	25		25	25		25
H0028	056	0	1	02	01	H0028_056_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	25						25			25			25		25
H0028	056	0	1	02	01	H0028_056_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	0		0				0		0	0		0	0		0
H0028	059	0	1	01	01	H0028_059_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	0		0				25		25	0		0	0		0
H0028	059	0	1	01	01	H0028_059_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	059	0	1	01	01	H0028_059_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	059	0	1	01	01	H0028_059_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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	25		25				25		25	25		25	25		25
H0028	059	0	1	01	01	H0028_059_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	25						25			25			25		25
H0028	060	0	1	01	01	H0028_060_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	060	0	1	01	01	H0028_060_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		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	25		25				25		25	25		0	25		25
H0028	060	0	1	01	01	H0028_060_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	45.00		135.00																									47.00		141.00				45.00		90.00				45.00				45.00		1.50				1.57	1.50	1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	060	0	1	01	01	H0028_060_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	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	25		25				25		25	25		25	25		25
H0028	060	0	1	01	01	H0028_060_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H0028	060	0	1	01	01	H0028_060_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	0		0				0		0	0		0	0		0
H0028	062	0	1	01	01	H0028_062_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	0		0				25		25	0		0	0		0
H0028	062	0	1	01	01	H0028_062_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	0		0				25		25	0		0	0		0
H0028	062	0	1	01	01	H0028_062_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	25		25				25		25	25		25	25		25
H0028	062	0	1	01	01	H0028_062_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	062	0	1	01	01	H0028_062_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	25						25			25			25		25
H0028	063	0	1	01	01	H0028_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	0		0				25		25	0		0	0		0
H0028	063	0	1	01	01	H0028_063_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	063	0	1	01	01	H0028_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		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	25		25				25		25	25		25	25		25
H0028	063	0	1	01	01	H0028_063_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	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	25		25				25		25	25		25	25		25
H0028	063	0	1	01	01	H0028_063_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	25						25			25			25		25
H0028	065	0	1	01	01	H0028_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																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	065	0	1	01	01	H0028_065_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	065	0	1	01	01	H0028_065_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	25		25				25		25	25		25	25		25
H0028	065	0	1	01	01	H0028_065_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	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	25		25				25		25	25		25	25		25
H0028	065	0	1	01	01	H0028_065_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	25						25			25			25		25
H0028	066	0	1	02	01	H0028_066_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	0		0				25		25	0		0	0		0
H0028	066	0	1	02	01	H0028_066_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	066	0	1	02	01	H0028_066_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	25		25				25		25	25		25	25		25
H0028	066	0	1	02	01	H0028_066_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H0028	066	0	1	02	01	H0028_066_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	25						25			25			25		25
H0028	067	0	1	02	01	H0028_067_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	0		0				25		25	0		0	0		0
H0028	067	0	1	02	01	H0028_067_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	067	0	1	02	01	H0028_067_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H0028	067	0	1	02	01	H0028_067_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				44.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H0028	067	0	1	02	01	H0028_067_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	0		0				0		0	0		0	0		0
H0028	070	0	1	01	01	H0028_070_0	2			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	0		0				25		25	0		0	0		0
H0028	070	0	1	01	01	H0028_070_0	2			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	0		0				25		25	0		0	0		0
H0028	070	0	1	01	01	H0028_070_0	2			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	25		25				25		25	25		25	25		25
H0028	070	0	1	01	01	H0028_070_0	2			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	25		25				25		25	25		25	25		25
H0028	070	0	1	01	01	H0028_070_0	2			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	25						25			25			25		25
H0028	072	0	1	01	01	H0028_072_0	2			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	0		0				25		25	0		0	0		0
H0028	072	0	1	01	01	H0028_072_0	2			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	25		25				25		25	25		0	25		25
H0028	072	0	1	01	01	H0028_072_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H0028	072	0	1	01	01	H0028_072_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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	25		25				25		25	25		25	25		25
H0028	072	0	1	01	01	H0028_072_0	2			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	25						25			25			25		25
H0028	074	1	1	01	01	H0028_074_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	0		0				25		25	0		0	0		0
H0028	074	1	1	01	01	H0028_074_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	25		25				25		25	25		0	25		25
H0028	074	1	1	01	01	H0028_074_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		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	25		25				25		25	25		25	25		25
H0028	074	1	1	01	01	H0028_074_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	074	1	1	01	01	H0028_074_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	25						25			25			25		25
H0028	074	2	1	01	01	H0028_074_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	0		0				25		25	0		0	0		0
H0028	074	2	1	01	01	H0028_074_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	25		25				25		25	25		0	25		25
H0028	074	2	1	01	01	H0028_074_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		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	25		25				25		25	25		25	25		25
H0028	074	2	1	01	01	H0028_074_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	074	2	1	01	01	H0028_074_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	25						25			25			25		25
H0028	076	0	1	01	01	H0028_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, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H0028	076	0	1	01	01	H0028_076_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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				59.00	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	25		25				25		25	25		25	25		25
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				46.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H0028	076	0	1	01	01	H0028_076_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	0		0				0		0	0		0	0		0
H0028	077	0	1	01	01	H0028_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, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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	0.00		0.00																									20.00		60.00				0.00		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	0		0				25		25	0		0	0		0
H0028	077	0	1	01	01	H0028_077_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H0028	077	0	1	01	01	H0028_077_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				41.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H0028	078	0	1	01	01	H0028_078_0	5		N	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	0		0				25		25	0		0	0		0
H0028	078	0	1	01	01	H0028_078_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	0		0				25		25	0		0	0		0
H0028	078	0	1	01	01	H0028_078_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	078	0	1	01	01	H0028_078_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	078	0	1	01	01	H0028_078_0	5		N	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	25						25			25			25		25
H0028	079	0	1	01	01	H0028_079_0	4		N	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	0		0				25		25	0		0	0		0
H0028	079	0	1	01	01	H0028_079_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	0		0				25		25	0		0	0		0
H0028	079	0	1	01	01	H0028_079_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	079	0	1	01	01	H0028_079_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	079	0	1	01	01	H0028_079_0	4		N	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	25						25			25			25		25
H0028	080	0	1	01	01	H0028_080_0	4		N	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	0		0				25		25	0		0	0		0
H0028	080	0	1	01	01	H0028_080_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	0		0				25		25	0		0	0		0
H0028	080	0	1	01	01	H0028_080_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	080	0	1	01	01	H0028_080_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0028	080	0	1	01	01	H0028_080_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	25						25			25			25		25
H0028	081	1	1	01	01	H0028_081_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	0		0				25		25	0		0	0		0
H0028	081	1	1	01	01	H0028_081_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	25		25				25		25	25		0	25		25
H0028	081	1	1	01	01	H0028_081_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		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	25		25				25		25	25		25	25		25
H0028	081	1	1	01	01	H0028_081_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H0028	081	1	1	01	01	H0028_081_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	25						25			25			25		25
H0028	081	2	1	01	01	H0028_081_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	0		0				25		25	0		0	0		0
H0028	081	2	1	01	01	H0028_081_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	25		25				25		25	25		0	25		25
H0028	081	2	1	01	01	H0028_081_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		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	25		25				25		25	25		25	25		25
H0028	081	2	1	01	01	H0028_081_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H0028	081	2	1	01	01	H0028_081_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	25						25			25			25		25
H0028	082	0	1	01	01	H0028_082_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	0		0				25		25	0		0	0		0
H0028	082	0	1	01	01	H0028_082_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0028	082	0	1	01	01	H0028_082_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	25		25				25		25	25		25	25		25
H0028	082	0	1	01	01	H0028_082_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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	25		25				25		25	25		25	25		25
H0028	082	0	1	01	01	H0028_082_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	25						25			25			25		25
H0029	007	0	1	02	01	H0029_007_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	007	0	1	02	01	H0029_007_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	007	0	1	02	01	H0029_007_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.21	25	25	25				97.21	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	007	0	1	02	01	H0029_007_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	007	0	1	02	01	H0029_007_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	007	0	1	02	01	H0029_007_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	008	0	1	02	01	H0029_008_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	008	0	1	02	01	H0029_008_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	008	0	1	02	01	H0029_008_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											101.55	25	25	25				101.55	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	008	0	1	02	01	H0029_008_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	008	0	1	02	01	H0029_008_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	008	0	1	02	01	H0029_008_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0029	009	0	1	02	01	H0029_009_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0029	009	0	1	02	01	H0029_009_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0029	009	0	1	02	01	H0029_009_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.73	25	25	25				119.73	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	009	0	1	02	01	H0029_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											63.73	44	44	44				63.73	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	009	0	1	02	01	H0029_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	009	0	1	02	01	H0029_009_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	010	0	1	02	01	H0029_010_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	010	0	1	02	01	H0029_010_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	010	0	1	02	01	H0029_010_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											101.05	25	25	25				101.05	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	010	0	1	02	01	H0029_010_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	010	0	1	02	01	H0029_010_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	010	0	1	02	01	H0029_010_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0029	011	0	1	02	01	H0029_011_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0029	011	0	1	02	01	H0029_011_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0029	011	0	1	02	01	H0029_011_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.26	25	25	25				123.26	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	011	0	1	02	01	H0029_011_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											56.83	36	36	36				55.25	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0029	011	0	1	02	01	H0029_011_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0029	011	0	1	02	01	H0029_011_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	011	0	1	01	01	H0062_011_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					8.00	16.00	24.00												38.00	57.00					16.00	0.00				19.00				19.00			0.63	0.27				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	011	0	1	01	01	H0062_011_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	011	0	1	01	01	H0062_011_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.12	20	20	20				79.12	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0062	011	0	1	01	01	H0062_011_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0062	011	0	1	01	01	H0062_011_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	011	0	1	01	01	H0062_011_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	012	0	1	01	01	H0062_012_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	012	0	1	01	01	H0062_012_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	012	0	1	01	01	H0062_012_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											95.74	21	21	21				95.74	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H0062	012	0	1	01	01	H0062_012_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0062	012	0	1	01	01	H0062_012_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0062	012	0	1	01	01	H0062_012_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0074	001	0	1	04	01	H0074_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0074	001	0	1	04	01	H0074_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											124.49	25	25	25				124.49	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0074	001	0	1	04	01	H0074_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.93	37	37	37				70.96	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0074	001	0	1	04	01	H0074_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0074	001	0	1	04	01	H0074_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0074	004	0	1	04	01	H0074_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.15	22	22	22				86.15	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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	22	22	22		22	22		22	22	22		22
H0074	004	0	1	04	01	H0074_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0074	004	0	1	04	01	H0074_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0104	012	0	1	04	01	H0104_012_0	6			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	25		25				25		25				25		25
H0104	012	0	1	04	01	H0104_012_0	6			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		40.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00		40.00				20.00		40.00				20.00		20.00	25		25				25		25				25		25
H0104	012	0	1	04	01	H0104_012_0	6			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		94.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	012	0	1	04	01	H0104_012_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				99.04	47		47																		47		47															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	012	0	1	04	01	H0104_012_0	6			Specialty Tier	4	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				51.66	30		30																		30		30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0104	014	0	1	04	01	H0104_014_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	25		25				25		25				25		25
H0104	014	0	1	04	01	H0104_014_0	7			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	20.00		40.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00		40.00				20.00		40.00				20.00		20.00	25		25				25		25				25		25
H0104	014	0	1	04	01	H0104_014_0	7			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	45.00		90.00																			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		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	014	0	1	04	01	H0104_014_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				95.70	44		44																		44		44															44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	014	0	1	04	01	H0104_014_0	7			Specialty Tier	4	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				47.15	28		28																		28		28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0104	015	0	1	04	01	H0104_015_0	6			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	25		25				25		25				25		25
H0104	015	0	1	04	01	H0104_015_0	6			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	15.00		30.00																			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		30.00				15.00		30.00				15.00		15.00	25		25				25		25				25		25
H0104	015	0	1	04	01	H0104_015_0	6			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	42.00		84.00																			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		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	015	0	1	04	01	H0104_015_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				82.10	35		35																		35		35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H0104	015	0	1	04	01	H0104_015_0	6			Specialty Tier	4	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				33.48	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	25		25				25		25				25		25
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	20.00		40.00																			20.00		40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00		40.00				20.00		40.00				20.00		20.00	25		25				25		25				25		25
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				33.98	18		18																		18		18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	18		18				18		18				18		18
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				56.16	30		30																		30		30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
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				579.47	29		29																		29		29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0107	003	0	1	04	01	H0107_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	003	0	1	04	01	H0107_003_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	003	0	1	04	01	H0107_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											47.16	19	19	19				45.64	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H0107	003	0	1	04	01	H0107_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											66.61	41	41	41				74.31	38	38	38										41	41	41				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	003	0	1	04	01	H0107_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											482.43	27						672.60	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0107	004	0	1	04	01	H0107_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	004	0	1	04	01	H0107_004_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	004	0	1	04	01	H0107_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											47.05	21	21	21				47.84	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	18	18	18	21	21	21	18	18	18	21		21
H0107	004	0	1	04	01	H0107_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											59.04	41	41	41				77.12	39	39	39										41	41	41				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	004	0	1	04	01	H0107_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											428.91	29						646.38	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0107	005	0	1	04	01	H0107_005_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	005	0	1	04	01	H0107_005_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	005	0	1	04	01	H0107_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											36.38	21	21	21				31.95	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	21	17	17	17	21		21
H0107	005	0	1	04	01	H0107_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											63.14	35	35	35				76.47	32	32	32										35	35	35				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	005	0	1	04	01	H0107_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											466.68	25						651.66	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0107	007	0	1	04	01	H0107_007_0	5			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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	007	0	1	04	01	H0107_007_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	007	0	1	04	01	H0107_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											31.71	19	19	19				30.74	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H0107	007	0	1	04	01	H0107_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											59.75	35	35	35				72.81	33	33	33										35	35	35				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	007	0	1	04	01	H0107_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											537.69	25						626.84	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0107	010	0	1	04	01	H0107_010_0	6			Preferred Generic	4	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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	010	0	1	04	01	H0107_010_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	010	0	1	04	01	H0107_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											41.64	21	21	21				32.92	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	21	17	17	17	21		21
H0107	010	0	1	04	01	H0107_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											65.91	37	37	37				78.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0107	010	0	1	04	01	H0107_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											618.13	25						647.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0111	001	0	1	04	01	H0111_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0111	001	0	1	04	01	H0111_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0111	001	0	1	04	01	H0111_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											126.85	25	25	25				126.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0111	001	0	1	04	01	H0111_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											65.98	37	37	37				65.98	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0111	001	0	1	04	01	H0111_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0111	001	0	1	04	01	H0111_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					5.00	10.00	15.00												38.00	57.00					10.00	0.00				19.00				19.00			0.63	0.17				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0111	004	0	1	04	01	H0111_004_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.96	20	20	20				83.96	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0111	004	0	1	04	01	H0111_004_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0111	004	0	1	04	01	H0111_004_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0154	011	0	1	01	01	H0154_011_0	3			Preferred Generic	4	11	1	2	1	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	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	0	0	0				25	25	25	0	0	0	0		0
H0154	011	0	1	01	01	H0154_011_0	3			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	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	25	25	25				25	25	25	25	25	25	25		25
H0154	011	0	1	01	01	H0154_011_0	3			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H0154	011	0	1	01	01	H0154_011_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				99.20	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	25	25	25				25	25	25	25	25	25	25		25
H0154	011	0	1	01	01	H0154_011_0	3			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	25												25		25
H0154	015	1	1	01	01	H0154_015_1	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																									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	0	0	0				25	25	25	0	0	0	0		0
H0154	015	1	1	01	01	H0154_015_1	3			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	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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	1	1	01	01	H0154_015_1	3			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	1	1	01	01	H0154_015_1	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31				99.16	42	42	42																								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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	1	1	01	01	H0154_015_1	3			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	25												25		25
H0154	015	2	1	01	01	H0154_015_2	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																									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	0	0	0				25	25	25	0	0	0	0		0
H0154	015	2	1	01	01	H0154_015_2	3			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	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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	2	1	01	01	H0154_015_2	3			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	2	1	01	01	H0154_015_2	3			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31				99.16	42	42	42																								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	25	25	25				25	25	25	25	25	25	25		25
H0154	015	2	1	01	01	H0154_015_2	3			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	25												25		25
H0154	017	0	1	01	01	H0154_017_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																									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	0	0	0				25	25	25	0	0	0	0		0
H0154	017	0	1	01	01	H0154_017_0	3			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	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	25	25	25				25	25	25	25	25	25	25		25
H0154	017	0	1	01	01	H0154_017_0	3			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H0154	017	0	1	01	01	H0154_017_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				99.48	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	25	25	25				25	25	25	25	25	25	25		25
H0154	017	0	1	01	01	H0154_017_0	3			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	25												25		25
H0154	020	0	1	01	01	H0154_020_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																									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	0	0	0				25	25	25	0	0	0	0		0
H0154	020	0	1	01	01	H0154_020_0	3			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	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	25	25	25				25	25	25	25	25	25	25		25
H0154	020	0	1	01	01	H0154_020_0	3			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
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	100				1	2				30	60	100	30		31				98.83	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	25	25	25				25	25	25	25	25	25	25		25
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	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H0169	001	0	1	02	01	H0169_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	001	0	1	02	01	H0169_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	001	0	1	02	01	H0169_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H0169	001	0	1	02	01	H0169_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	001	0	1	02	01	H0169_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				345.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	002	0	1	02	01	H0169_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	002	0	1	02	01	H0169_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	002	0	1	02	01	H0169_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H0169	002	0	1	02	01	H0169_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	002	0	1	02	01	H0169_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				360.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	003	0	1	02	01	H0169_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	003	0	1	02	01	H0169_003_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	003	0	1	02	01	H0169_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H0169	003	0	1	02	01	H0169_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				52.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	003	0	1	02	01	H0169_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				354.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	004	0	1	02	01	H0169_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	004	0	1	02	01	H0169_004_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	004	0	1	02	01	H0169_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H0169	004	0	1	02	01	H0169_004_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	004	0	1	02	01	H0169_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				354.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	006	0	1	02	01	H0169_006_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	006	0	1	02	01	H0169_006_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	006	0	1	02	01	H0169_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H0169	006	0	1	02	01	H0169_006_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				52.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	006	0	1	02	01	H0169_006_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				389.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	008	0	1	02	01	H0169_008_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	008	0	1	02	01	H0169_008_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	008	0	1	02	01	H0169_008_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H0169	008	0	1	02	01	H0169_008_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	008	0	1	02	01	H0169_008_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				349.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	009	0	1	02	01	H0169_009_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	009	0	1	02	01	H0169_009_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0169	009	0	1	02	01	H0169_009_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H0169	009	0	1	02	01	H0169_009_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	009	0	1	02	01	H0169_009_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				361.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	010	0	1	02	01	H0169_010_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0169	010	0	1	02	01	H0169_010_0	4		N	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																														
H0169	010	0	1	02	01	H0169_010_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H0169	010	0	1	02	01	H0169_010_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				35.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0169	010	0	1	02	01	H0169_010_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				341.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0174	004	0	1	01	01	H0174_004_0	6		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	004	0	1	01	01	H0174_004_0	6		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	004	0	1	01	01	H0174_004_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											85.58	20	20	20				85.58	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0174	004	0	1	01	01	H0174_004_0	6		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											42.00	32	32	32				42.00	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	004	0	1	01	01	H0174_004_0	6		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	004	0	1	01	01	H0174_004_0	6		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	006	0	1	01	01	H0174_006_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	006	0	1	01	01	H0174_006_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	006	0	1	01	01	H0174_006_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.36	20	20	20				82.36	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0174	006	0	1	01	01	H0174_006_0	7		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											38.30	30	30	30				38.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	006	0	1	01	01	H0174_006_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	006	0	1	01	01	H0174_006_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	009	0	1	01	01	H0174_009_0	7			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	7			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											90.94	21	21	21				86.61	20	20	20											21	21					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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	20	20	20		21	21		20	20	21		21
H0174	009	0	1	01	01	H0174_009_0	7			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	009	0	1	01	01	H0174_009_0	7			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	7			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	010	0	1	01	01	H0174_010_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	010	0	1	01	01	H0174_010_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	010	0	1	01	01	H0174_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.75	25	25	25				130.75	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	010	0	1	01	01	H0174_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.59	36	36	36				81.27	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	010	0	1	01	01	H0174_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	010	0	1	01	01	H0174_010_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	014	0	1	01	01	H0174_014_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	014	0	1	01	01	H0174_014_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.75	25	25	25				120.75	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	014	0	1	01	01	H0174_014_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											73.28	37	37	37				71.30	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	014	0	1	01	01	H0174_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	014	0	1	01	01	H0174_014_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	015	0	1	01	01	H0174_015_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	015	0	1	01	01	H0174_015_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.27	25	25	25				129.27	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	015	0	1	01	01	H0174_015_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.12	37	37	37				74.12	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	015	0	1	01	01	H0174_015_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	015	0	1	01	01	H0174_015_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	016	0	1	01	01	H0174_016_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	016	0	1	01	01	H0174_016_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.29	25	25	25				130.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	016	0	1	01	01	H0174_016_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.15	35	35	35				77.15	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	016	0	1	01	01	H0174_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	016	0	1	01	01	H0174_016_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	017	0	1	01	01	H0174_017_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	017	0	1	01	01	H0174_017_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											117.19	25	25	25				117.19	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	017	0	1	01	01	H0174_017_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											81.85	50	50	50				81.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	017	0	1	01	01	H0174_017_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	017	0	1	01	01	H0174_017_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	018	0	1	01	01	H0174_018_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	018	0	1	01	01	H0174_018_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											109.20	25	25	25				109.20	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	018	0	1	01	01	H0174_018_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											87.95	50	50	50				87.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	018	0	1	01	01	H0174_018_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	018	0	1	01	01	H0174_018_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	019	0	1	01	01	H0174_019_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	019	0	1	01	01	H0174_019_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.49	25	25	25				119.49	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	019	0	1	01	01	H0174_019_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.00	46	46	46				98.00	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	019	0	1	01	01	H0174_019_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	019	0	1	01	01	H0174_019_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	020	0	1	01	01	H0174_020_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	020	0	1	01	01	H0174_020_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											125.07	25	25	25				125.07	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	020	0	1	01	01	H0174_020_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											85.17	50	50	50				85.17	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	020	0	1	01	01	H0174_020_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	020	0	1	01	01	H0174_020_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0174	021	0	1	01	01	H0174_021_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0174	021	0	1	01	01	H0174_021_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											131.29	25	25	25				131.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	021	0	1	01	01	H0174_021_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											90.77	43	43	43				88.66	42	42	42											43	43					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	021	0	1	01	01	H0174_021_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	021	0	1	01	01	H0174_021_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	022	0	1	01	01	H0174_022_0	6		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	022	0	1	01	01	H0174_022_0	6		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	022	0	1	01	01	H0174_022_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											102.06	25	25	25				102.06	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	022	0	1	01	01	H0174_022_0	6		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	022	0	1	01	01	H0174_022_0	6		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	022	0	1	01	01	H0174_022_0	6		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	023	0	1	01	01	H0174_023_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	023	0	1	01	01	H0174_023_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	023	0	1	01	01	H0174_023_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.37	25	25	25				98.37	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	023	0	1	01	01	H0174_023_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	023	0	1	01	01	H0174_023_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	023	0	1	01	01	H0174_023_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	024	0	1	01	01	H0174_024_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	024	0	1	01	01	H0174_024_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	024	0	1	01	01	H0174_024_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.83	25	25	25				98.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	024	0	1	01	01	H0174_024_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	024	0	1	01	01	H0174_024_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	024	0	1	01	01	H0174_024_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	025	0	1	01	01	H0174_025_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	025	0	1	01	01	H0174_025_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	025	0	1	01	01	H0174_025_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											87.55	20	20	20				87.55	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0174	025	0	1	01	01	H0174_025_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	025	0	1	01	01	H0174_025_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	025	0	1	01	01	H0174_025_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	026	0	1	01	01	H0174_026_0	6		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					4.00	8.00	12.00												38.00	57.00					8.00	0.00				19.00				19.00			0.63	0.13				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	026	0	1	01	01	H0174_026_0	6		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	026	0	1	01	01	H0174_026_0	6		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											80.59	20	20	20				80.59	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0174	026	0	1	01	01	H0174_026_0	6		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0174	026	0	1	01	01	H0174_026_0	6		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0174	026	0	1	01	01	H0174_026_0	6		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0251	002	0	1	02	01	H0251_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0251	002	0	1	02	01	H0251_002_0	4		N	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																														
H0251	002	0	1	02	01	H0251_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H0251	002	0	1	02	01	H0251_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0251	002	0	1	02	01	H0251_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0251	008	0	1	02	01	H0251_008_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0251	008	0	1	02	01	H0251_008_0	4		N	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																														
H0251	008	0	1	02	01	H0251_008_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H0251	008	0	1	02	01	H0251_008_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0251	008	0	1	02	01	H0251_008_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				361.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0270	001	0	1	04	01	H0270_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0270	001	0	1	04	01	H0270_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0270	001	0	1	04	01	H0270_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											118.11	25	25	25				118.11	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0270	001	0	1	04	01	H0270_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											60.32	37	37	37				58.69	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0270	001	0	1	04	01	H0270_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0270	001	0	1	04	01	H0270_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	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	0		0				25		25	0		0	0		0
H0292	001	0	1	01	01	H0292_001_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	0		0				25		25	0		0	0		0
H0292	001	0	1	01	01	H0292_001_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	25		25				25		25	25		25	25		25
H0292	001	0	1	01	01	H0292_001_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	25		25				25		25	25		25	25		25
H0292	001	0	1	01	01	H0292_001_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	25						25			25			25		25
H0292	002	0	1	01	01	H0292_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	0		0				25		25	0		0	0		0
H0292	002	0	1	01	01	H0292_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	25		25				25		25	25		0	25		25
H0292	002	0	1	01	01	H0292_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	25		25				25		25	25		25	25		25
H0292	002	0	1	01	01	H0292_002_0	4			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	25		25				25		25	25		25	25		25
H0292	002	0	1	01	01	H0292_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	25						25			25			25		25
H0292	003	0	1	01	01	H0292_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	0		0				25		25	0		0	0		0
H0292	003	0	1	01	01	H0292_003_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	0		0				25		25	0		0	0		0
H0292	003	0	1	01	01	H0292_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	25		25				25		25	25		25	25		25
H0292	003	0	1	01	01	H0292_003_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	25		25				25		25	25		25	25		25
H0292	003	0	1	01	01	H0292_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	25						25			25			25		25
H0294	002	0	1	04	01	H0294_002_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	002	0	1	04	01	H0294_002_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	002	0	1	04	01	H0294_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H0294	002	0	1	04	01	H0294_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				61.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0294	002	0	1	04	01	H0294_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H0294	004	0	1	04	01	H0294_004_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	004	0	1	04	01	H0294_004_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	004	0	1	04	01	H0294_004_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H0294	004	0	1	04	01	H0294_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	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	25						25			25			25		25
H0294	004	0	1	04	01	H0294_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H0294	015	0	1	04	01	H0294_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	015	0	1	04	01	H0294_015_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	015	0	1	04	01	H0294_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0294	015	0	1	04	01	H0294_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0294	015	0	1	04	01	H0294_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				398.00	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	25						25			25			25		25
H0294	016	0	1	04	01	H0294_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	016	0	1	04	01	H0294_016_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	016	0	1	04	01	H0294_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0294	016	0	1	04	01	H0294_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0294	016	0	1	04	01	H0294_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H0294	017	0	1	04	01	H0294_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	017	0	1	04	01	H0294_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	017	0	1	04	01	H0294_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0294	017	0	1	04	01	H0294_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0294	017	0	1	04	01	H0294_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				384.00	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	25						25			25			25		25
H0294	018	0	1	04	01	H0294_018_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	018	0	1	04	01	H0294_018_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	018	0	1	04	01	H0294_018_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0294	018	0	1	04	01	H0294_018_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0294	018	0	1	04	01	H0294_018_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				356.00	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	25						25			25			25		25
H0294	027	0	1	04	01	H0294_027_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0294	027	0	1	04	01	H0294_027_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	027	0	1	04	01	H0294_027_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H0294	027	0	1	04	01	H0294_027_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	027	0	1	04	01	H0294_027_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	032	0	1	04	01	H0294_032_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	032	0	1	04	01	H0294_032_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	032	0	1	04	01	H0294_032_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0294	032	0	1	04	01	H0294_032_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	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	25						25			25			25		25
H0294	032	0	1	04	01	H0294_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				362.00	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	25						25			25			25		25
H0294	049	0	1	04	01	H0294_049_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0294	049	0	1	04	01	H0294_049_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				9.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	049	0	1	04	01	H0294_049_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	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	25		25						25				25		25
H0294	049	0	1	04	01	H0294_049_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	049	0	1	04	01	H0294_049_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				404.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	050	0	1	04	01	H0294_050_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0294	050	0	1	04	01	H0294_050_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0294	050	0	1	04	01	H0294_050_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H0294	050	0	1	04	01	H0294_050_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	050	0	1	04	01	H0294_050_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				418.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	051	0	1	04	01	H0294_051_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0294	051	0	1	04	01	H0294_051_0	4		N	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																														
H0294	051	0	1	04	01	H0294_051_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				60.00	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	25		25						25				25		25
H0294	051	0	1	04	01	H0294_051_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				53.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0294	051	0	1	04	01	H0294_051_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				408.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0302	001	0	1	01	01	H0302_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H0302	001	0	1	01	01	H0302_001_0	6			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	20	20	20				20	20	20				20		20
H0302	001	0	1	01	01	H0302_001_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	20	20	20				20	20	20				20		20
H0302	001	0	1	01	01	H0302_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	20	20	20				20	20	20				20		20
H0302	001	0	1	01	01	H0302_001_0	6			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31				482.06	28	28																																				28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00											35.00		35.00	20	20											20		20
H0302	001	0	1	01	01	H0302_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H0302	006	0	1	01	01	H0302_006_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H0302	006	0	1	01	01	H0302_006_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00	20	20	20				20	20	20				20		20
H0302	006	0	1	01	01	H0302_006_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				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	20	20	20				20	20	20				20		20
H0302	006	0	1	01	01	H0302_006_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				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	20	20	20				20	20	20				20		20
H0302	006	0	1	01	01	H0302_006_0	7			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31				508.06	28	28																																				28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00											35.00		35.00	20	20											20		20
H0302	006	0	1	01	01	H0302_006_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H0302	008	0	1	01	01	H0302_008_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H0302	008	0	1	01	01	H0302_008_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	9.00	9.00	9.00																			9.00	9.00	9.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	9.00	9.00	9.00				9.00	9.00	9.00				9.00		9.00	20	20	20				20	20	20				20		20
H0302	008	0	1	01	01	H0302_008_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	20	20	20				20	20	20				20		20
H0302	008	0	1	01	01	H0302_008_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				100.00		3.33			3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	20	20	20				20	20	20				20		20
H0302	008	0	1	01	01	H0302_008_0	8			Specialty Tier	4	11	1	1	5	1	011		01	000		1	30	60					1	2							30		31				507.09	28	28																																				28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00											35.00		35.00	20	20											20		20
H0302	008	0	1	01	01	H0302_008_0	8			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H0321	002	0	1	02	01	H0321_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0321	002	0	1	02	01	H0321_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0321	002	0	1	02	01	H0321_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H0321	002	0	1	02	01	H0321_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0321	002	0	1	02	01	H0321_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0332	004	0	1	02	01	H0332_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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0332	004	0	1	02	01	H0332_004_0	7			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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0332	004	0	1	02	01	H0332_004_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0332	004	0	1	02	01	H0332_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											99.86	35	35	35				69.99	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	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0332	004	0	1	02	01	H0332_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1380.67	30						1216.37	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	25			25			25			25			25		25
H0332	004	0	1	02	01	H0332_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H0332	009	0	1	01	01	H0332_009_0	7			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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0332	009	0	1	01	01	H0332_009_0	7			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	36.00					4.00	8.00	10.00											12.00	24.00	36.00				4.00	8.00	10.00				12.00				12.00			0.40	0.13		0.40	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	12.00	24.00	36.00	4.00	8.00	10.00	12.00	24.00	36.00	4.00	8.00	10.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0332	009	0	1	01	01	H0332_009_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											101.82	20	20	20				112.67	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	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H0332	009	0	1	01	01	H0332_009_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											86.91	30	30	30				60.93	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	87.50	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0332	009	0	1	01	01	H0332_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1028.48	30						1181.11	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	25			25			25			25			25		25
H0332	009	0	1	01	01	H0332_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		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H0342	001	0	1	04	01	H0342_001_0	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H0342	001	0	1	04	01	H0342_001_0	9			Generic	4	01	3	2	2	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					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H0342	001	0	1	04	01	H0342_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											44.73	20	20	20				44.02	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H0342	001	0	1	04	01	H0342_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											50.28	25	25	25				52.56	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	25	25	25	25	25	25	25	25	25				25		25
H0342	001	0	1	04	01	H0342_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												25							25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0342	001	0	1	04	01	H0342_001_0	9			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		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	038	0	1	01	01	H0351_038_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	038	0	1	01	01	H0351_038_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											95.56	25	25	25				95.56	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	038	0	1	01	01	H0351_038_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											47.79	44	44	44				46.70	43	43	43											44	44					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	038	0	1	01	01	H0351_038_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								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		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0		0	0		0	0	0		0
H0351	053	0	1	01	01	H0351_053_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	053	0	1	01	01	H0351_053_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	053	0	1	01	01	H0351_053_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.46	25	25	25				120.46	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	053	0	1	01	01	H0351_053_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.92	35	35	35				72.78	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	053	0	1	01	01	H0351_053_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	053	0	1	01	01	H0351_053_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	054	0	1	01	01	H0351_054_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	054	0	1	01	01	H0351_054_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											114.09	25	25	25				114.09	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	054	0	1	01	01	H0351_054_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.38	44	44	44				70.38	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	054	0	1	01	01	H0351_054_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	054	0	1	01	01	H0351_054_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	5			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	057	0	1	01	01	H0351_057_0	5			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	057	0	1	01	01	H0351_057_0	5			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.81	25	25	25				104.81	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	057	0	1	01	01	H0351_057_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											47.43	38	38	38				46.18	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	057	0	1	01	01	H0351_057_0	5			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	057	0	1	01	01	H0351_057_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0		0	0		0	0	0		0
H0351	063	0	1	01	01	H0351_063_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	063	0	1	01	01	H0351_063_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	063	0	1	01	01	H0351_063_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.04	25	25	25				119.04	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	063	0	1	01	01	H0351_063_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.36	33	33	33				83.74	32	32	32											33	33					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	063	0	1	01	01	H0351_063_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	063	0	1	01	01	H0351_063_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	064	0	1	01	01	H0351_064_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	064	0	1	01	01	H0351_064_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.79	25	25	25				116.79	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	064	0	1	01	01	H0351_064_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											96.43	43	43	43				96.43	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	064	0	1	01	01	H0351_064_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	064	0	1	01	01	H0351_064_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	065	0	1	01	01	H0351_065_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	065	0	1	01	01	H0351_065_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											131.05	25	25	25				131.05	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	065	0	1	01	01	H0351_065_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.93	34	34	34				67.87	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	065	0	1	01	01	H0351_065_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	065	0	1	01	01	H0351_065_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	066	0	1	02	01	H0351_066_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	066	0	1	02	01	H0351_066_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	066	0	1	02	01	H0351_066_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.10	25	25	25				99.10	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	066	0	1	02	01	H0351_066_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	066	0	1	02	01	H0351_066_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	066	0	1	02	01	H0351_066_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00												12.00	18.00					0.00	0.00				6.00				6.00			0.20	0.00				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	067	0	1	02	01	H0351_067_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	067	0	1	02	01	H0351_067_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	067	0	1	02	01	H0351_067_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											127.69	25	25	25				127.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	067	0	1	02	01	H0351_067_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.72	34	34	34				67.67	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	067	0	1	02	01	H0351_067_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	067	0	1	02	01	H0351_067_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	068	0	1	02	01	H0351_068_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	068	0	1	02	01	H0351_068_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	068	0	1	02	01	H0351_068_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.35	25	25	25				98.35	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	068	0	1	02	01	H0351_068_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	068	0	1	02	01	H0351_068_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	068	0	1	02	01	H0351_068_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00												12.00	18.00					0.00	0.00				6.00				6.00			0.20	0.00				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	069	0	1	02	01	H0351_069_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	069	0	1	02	01	H0351_069_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	069	0	1	02	01	H0351_069_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											103.15	25	25	25				103.15	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	069	0	1	02	01	H0351_069_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											53.34	35	35	35				51.82	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	069	0	1	02	01	H0351_069_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	069	0	1	02	01	H0351_069_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0		0	0		0	0	0		0
H0351	070	0	1	02	01	H0351_070_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0351	070	0	1	02	01	H0351_070_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0351	070	0	1	02	01	H0351_070_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											126.42	25	25	25				126.42	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	070	0	1	02	01	H0351_070_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.86	34	34	34				67.86	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0351	070	0	1	02	01	H0351_070_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0351	070	0	1	02	01	H0351_070_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0354	001	0	1	01	01	H0354_001_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0354	001	0	1	01	01	H0354_001_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											67.25	50	50	50				61.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											616.95	30						530.97	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					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, Select Diabetic Drugs	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0354	027	0	1	01	01	H0354_027_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0354	027	0	1	01	01	H0354_027_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											67.95	50	50	50				42.24	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											568.08	30						427.35	30												30						30					30			30								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	25			25			25			25			25		25
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	100	1	2				30	60	100	30		31								11.00	22.00	33.00					9.00	18.00	27.00											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	27.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0354	028	0	1	01	01	H0354_028_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0354	028	0	1	01	01	H0354_028_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											73.08	50	50	50				59.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											616.70	30						506.48	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0354	029	0	1	01	01	H0354_029_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0354	029	0	1	01	01	H0354_029_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											74.70	50	50	50				64.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											628.15	29						572.51	29												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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0354	030	0	1	01	01	H0354_030_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0354	030	0	1	01	01	H0354_030_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											71.04	50	50	50				60.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											572.54	27						542.34	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0413	001	0	1	04	01	H0413_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	0	0	0				0	0	0				0		0
H0413	001	0	1	04	01	H0413_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	0	0	0				0	0	0				0		0
H0413	001	0	1	04	01	H0413_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				33.00	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	19	19	19				19	19	19				19		19
H0413	001	0	1	04	01	H0413_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0413	001	0	1	04	01	H0413_001_0	7			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	25						25						25		25
H0413	002	0	1	04	01	H0413_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	0	0	0				0	0	0				0		0
H0413	002	0	1	04	01	H0413_002_0	6			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	25	25	25				25	25	25				25		25
H0413	002	0	1	04	01	H0413_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				39.00	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	21	21	21				21	21	21				21		21
H0413	002	0	1	04	01	H0413_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				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	25	25	25				25	25	25				25		25
H0413	002	0	1	04	01	H0413_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	25						25						25		25
H0413	003	0	1	04	01	H0413_003_0	7			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H0413	003	0	1	04	01	H0413_003_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H0413	003	0	1	04	01	H0413_003_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0413	003	0	1	04	01	H0413_003_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H0413	003	0	1	04	01	H0413_003_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H0413	003	0	1	04	01	H0413_003_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0421	001	0	1	04	01	H0421_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0421	001	0	1	04	01	H0421_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0421	001	0	1	04	01	H0421_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H0421	001	0	1	04	01	H0421_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0421	001	0	1	04	01	H0421_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0423	001	0	1	01	01	H0423_001_0	7		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																														
H0423	001	0	1	01	01	H0423_001_0	7		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	0	0	0				0	0	0				0		0
H0423	001	0	1	01	01	H0423_001_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				45.18	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	25	25	25				25	25	25				25		25
H0423	001	0	1	01	01	H0423_001_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				75.58	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	25	25	25				25	25	25				25		25
H0423	001	0	1	01	01	H0423_001_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	010		1	30	60	100				1	2	30						30		31				990.83	25	25	25																		25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00						35.00		35.00	25	25	25				25						25		25
H0432	003	0	1	02	01	H0432_003_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0432	003	0	1	02	01	H0432_003_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0432	003	0	1	02	01	H0432_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0432	003	0	1	02	01	H0432_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0432	003	0	1	02	01	H0432_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	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	25						25			25			25		25
H0432	004	0	1	02	01	H0432_004_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0432	004	0	1	02	01	H0432_004_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0432	004	0	1	02	01	H0432_004_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0432	004	0	1	02	01	H0432_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0432	004	0	1	02	01	H0432_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	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	25						25			25			25		25
H0432	009	0	1	02	01	H0432_009_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0432	009	0	1	02	01	H0432_009_0	4		N	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																														
H0432	009	0	1	02	01	H0432_009_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H0432	009	0	1	02	01	H0432_009_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0432	009	0	1	02	01	H0432_009_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0432	013	0	1	02	01	H0432_013_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0432	013	0	1	02	01	H0432_013_0	4		N	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																														
H0432	013	0	1	02	01	H0432_013_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H0432	013	0	1	02	01	H0432_013_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0432	013	0	1	02	01	H0432_013_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				347.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0432	017	0	1	02	01	H0432_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0432	017	0	1	02	01	H0432_017_0	4			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																														
H0432	017	0	1	02	01	H0432_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				63.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H0432	017	0	1	02	01	H0432_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	47																				47																	47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0432	017	0	1	02	01	H0432_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				363.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0439	002	0	1	01	01	H0439_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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	002	0	1	01	01	H0439_002_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	002	0	1	01	01	H0439_002_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											22.11	24	24	24				25.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0439	002	0	1	01	01	H0439_002_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											56.46	25	25	25				55.11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	002	0	1	01	01	H0439_002_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											470.70	25						431.91	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	25			25			25			25			25		25
H0439	003	1	1	01	01	H0439_003_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	003	1	1	01	01	H0439_003_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	003	1	1	01	01	H0439_003_1	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	003	1	1	01	01	H0439_003_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											67.77	50	50	50				56.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	003	1	1	01	01	H0439_003_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											519.96	25						438.00	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	25			25			25			25			25		25
H0439	003	2	1	01	01	H0439_003_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	003	2	1	01	01	H0439_003_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	003	2	1	01	01	H0439_003_2	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	003	2	1	01	01	H0439_003_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											67.77	50	50	50				56.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	003	2	1	01	01	H0439_003_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											519.96	25						438.00	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	25			25			25			25			25		25
H0439	006	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	006	0	1	01	01	H0439_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	006	0	1	01	01	H0439_006_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	006	0	1	01	01	H0439_006_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											68.69	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	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	006	0	1	01	01	H0439_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											531.00	25						423.05	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	25			25			25			25			25		25
H0439	008	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	008	0	1	01	01	H0439_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	008	0	1	01	01	H0439_008_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	008	0	1	01	01	H0439_008_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											74.30	50	50	50				65.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	008	0	1	01	01	H0439_008_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											680.24	25						446.35	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	25			25			25			25			25		25
H0439	009	0	1	01	01	H0439_009_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	009	0	1	01	01	H0439_009_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	009	0	1	01	01	H0439_009_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	009	0	1	01	01	H0439_009_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											63.94	50	50	50				60.10	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	009	0	1	01	01	H0439_009_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											510.01	30						597.40	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0439	010	0	1	01	01	H0439_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	010	0	1	01	01	H0439_010_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	010	0	1	01	01	H0439_010_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	010	0	1	01	01	H0439_010_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											59.25	50	50	50				62.01	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	010	0	1	01	01	H0439_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											645.83	30						541.48	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	25			25			25			25			25		25
H0439	011	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	011	0	1	01	01	H0439_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	011	0	1	01	01	H0439_011_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	011	0	1	01	01	H0439_011_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											69.97	50	50	50				57.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	011	0	1	01	01	H0439_011_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											686.57	30						619.17	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0439	012	0	1	01	01	H0439_012_0	4		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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	012	0	1	01	01	H0439_012_0	4		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	012	0	1	01	01	H0439_012_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											22.66	23	23	23				24.93	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H0439	012	0	1	01	01	H0439_012_0	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											54.23	25	25	25				56.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	012	0	1	01	01	H0439_012_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											500.33	25						443.15	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	25			25			25			25			25		25
H0439	013	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	013	0	1	01	01	H0439_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	013	0	1	01	01	H0439_013_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	013	0	1	01	01	H0439_013_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											71.65	50	50	50				60.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	013	0	1	01	01	H0439_013_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											603.93	25						486.37	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	25			25			25			25			25		25
H0439	015	1	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	015	1	1	01	01	H0439_015_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	015	1	1	01	01	H0439_015_1	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	015	1	1	01	01	H0439_015_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											92.85	50	50	50				61.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	015	1	1	01	01	H0439_015_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											654.90	28						510.22	28												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	25			25			25			25			25		25
H0439	015	2	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	015	2	1	01	01	H0439_015_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	015	2	1	01	01	H0439_015_2	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	015	2	1	01	01	H0439_015_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											92.85	50	50	50				61.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	015	2	1	01	01	H0439_015_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											654.90	28						510.22	28												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	25			25			25			25			25		25
H0439	016	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	016	0	1	01	01	H0439_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	016	0	1	01	01	H0439_016_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	016	0	1	01	01	H0439_016_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											88.85	50	50	50				63.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	016	0	1	01	01	H0439_016_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.60	25						461.13	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	25			25			25			25			25		25
H0439	017	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	017	0	1	01	01	H0439_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	017	0	1	01	01	H0439_017_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	017	0	1	01	01	H0439_017_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											67.51	50	50	50				59.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	017	0	1	01	01	H0439_017_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											529.36	25						468.79	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	25			25			25			25			25		25
H0439	018	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	018	0	1	01	01	H0439_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	018	0	1	01	01	H0439_018_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	018	0	1	01	01	H0439_018_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											70.40	50	50	50				59.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	018	0	1	01	01	H0439_018_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.62	25						474.23	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	25			25			25			25			25		25
H0439	019	0	1	01	01	H0439_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	019	0	1	01	01	H0439_019_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	019	0	1	01	01	H0439_019_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	019	0	1	01	01	H0439_019_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											70.40	50	50	50				59.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	019	0	1	01	01	H0439_019_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											589.62	25						474.23	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	25			25			25			25			25		25
H0439	020	0	1	01	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	020	0	1	01	01	H0439_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	020	0	1	01	01	H0439_020_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	020	0	1	01	01	H0439_020_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											74.28	50	50	50				65.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	020	0	1	01	01	H0439_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											731.05	30						597.92	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	25			25			25			25			25		25
H0439	021	0	1	01	01	H0439_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	021	0	1	01	01	H0439_021_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	021	0	1	01	01	H0439_021_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	021	0	1	01	01	H0439_021_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											60.71	50	50	50				51.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	021	0	1	01	01	H0439_021_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											757.39	33						618.53	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	25			25			25			25			25		25
H0439	022	0	1	01	01	H0439_022_0	4		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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	022	0	1	01	01	H0439_022_0	4		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	022	0	1	01	01	H0439_022_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											20.98	23	23	23				21.70	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H0439	022	0	1	01	01	H0439_022_0	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											51.20	25	25	25				55.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	022	0	1	01	01	H0439_022_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											475.81	25						465.21	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	25			25			25			25			25		25
H0439	023	0	1	01	01	H0439_023_0	4		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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	023	0	1	01	01	H0439_023_0	4		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	023	0	1	01	01	H0439_023_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											20.98	23	23	23				21.70	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H0439	023	0	1	01	01	H0439_023_0	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											51.20	25	25	25				55.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	023	0	1	01	01	H0439_023_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											475.81	25						465.21	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	25			25			25			25			25		25
H0439	024	0	1	02	01	H0439_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0439	024	0	1	02	01	H0439_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0439	024	0	1	02	01	H0439_024_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	024	0	1	02	01	H0439_024_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											61.35	50	50	50				65.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0439	024	0	1	02	01	H0439_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											559.42	30						607.47	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	25			25			25			25			25		25
H0473	003	0	1	04	01	H0473_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	0		0				25		25	0		0	0		0
H0473	003	0	1	04	01	H0473_003_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	25		25				25		25	25		0	25		25
H0473	003	0	1	04	01	H0473_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	25		25				25		25	25		25	25		25
H0473	003	0	1	04	01	H0473_003_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	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	25		25				25		25	25		25	25		25
H0473	003	0	1	04	01	H0473_003_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	25						25			25			25		25
H0473	004	0	1	04	01	H0473_004_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	0		0				25		25	0		0	0		0
H0473	004	0	1	04	01	H0473_004_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0473	004	0	1	04	01	H0473_004_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	25		25				25		25	25		25	25		25
H0473	004	0	1	04	01	H0473_004_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0473	004	0	1	04	01	H0473_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	25						25			25			25		25
H0473	005	0	1	04	01	H0473_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	0		0				25		25	0		0	0		0
H0473	005	0	1	04	01	H0473_005_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H0473	005	0	1	04	01	H0473_005_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H0473	005	0	1	04	01	H0473_005_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	25		25				25		25	25		25	25		25
H0473	005	0	1	04	01	H0473_005_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	25						25			25			25		25
H0504	015	0	1	01	01	H0504_015_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	015	0	1	01	01	H0504_015_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											51.36	20	20	20				51.54	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	015	0	1	01	01	H0504_015_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											104.43	25	25	25				73.78	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	015	0	1	01	01	H0504_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											578.26	29						402.07	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	017	0	1	01	01	H0504_017_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	017	0	1	01	01	H0504_017_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											53.54	20	20	20				50.89	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	017	0	1	01	01	H0504_017_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											108.18	25	25	25				81.51	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	017	0	1	01	01	H0504_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											627.06	29						438.99	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	021	0	1	01	01	H0504_021_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	021	0	1	01	01	H0504_021_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											48.57	20	20	20				50.69	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	021	0	1	01	01	H0504_021_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											99.78	25	25	25				70.70	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	021	0	1	01	01	H0504_021_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											648.38	29						427.20	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	026	0	1	01	01	H0504_026_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	026	0	1	01	01	H0504_026_0	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											52.10	20	20	20				51.56	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	026	0	1	01	01	H0504_026_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											104.47	25	25	25				74.07	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	026	0	1	01	01	H0504_026_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											633.75	29						439.15	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	028	0	1	01	01	H0504_028_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	028	0	1	01	01	H0504_028_0	5			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					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	028	0	1	01	01	H0504_028_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											55.05	20	20	20				56.83	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	028	0	1	01	01	H0504_028_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											107.59	25	25	25				74.88	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	028	0	1	01	01	H0504_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											692.26	30						431.46	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	038	0	1	01	01	H0504_038_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	038	0	1	01	01	H0504_038_0	5			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	038	0	1	01	01	H0504_038_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											66.75	25	25	25				68.37	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	038	0	1	01	01	H0504_038_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											91.29	30	30	30				77.51	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0504	038	0	1	01	01	H0504_038_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											495.66	28						292.58	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	039	0	1	01	01	H0504_039_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	039	0	1	01	01	H0504_039_0	5			Generic	4	01	3	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	039	0	1	01	01	H0504_039_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											64.62	25	25	25				71.25	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	039	0	1	01	01	H0504_039_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											99.92	30	30	30				74.49	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0504	039	0	1	01	01	H0504_039_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											533.84	28						421.74	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	040	0	1	01	01	H0504_040_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	040	0	1	01	01	H0504_040_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											55.56	20	20	20				58.26	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	040	0	1	01	01	H0504_040_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											103.15	25	25	25				75.27	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	040	0	1	01	01	H0504_040_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											702.45	29						429.43	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	041	0	1	01	01	H0504_041_0	6			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	041	0	1	01	01	H0504_041_0	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											63.67	24	24	24				66.23	24	24	24						24															24			24								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	24	24	24	24	24	24			24				24		24
H0504	041	0	1	01	01	H0504_041_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											98.45	29	29	29				73.83	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0504	041	0	1	01	01	H0504_041_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											502.43	28						349.86	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	043	0	1	01	01	H0504_043_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	043	0	1	01	01	H0504_043_0	5			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					0.00	0.00	0.00							0.00																10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	043	0	1	01	01	H0504_043_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											55.68	20	20	20				54.34	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	043	0	1	01	01	H0504_043_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											104.26	25	25	25				70.84	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	043	0	1	01	01	H0504_043_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											608.81	30						493.10	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	047	0	1	01	01	H0504_047_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	047	0	1	01	01	H0504_047_0	5			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	047	0	1	01	01	H0504_047_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											68.46	24	24	24				66.74	24	24	24						24															24			24								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	24	24	24	24	24	24			24				24		24
H0504	047	0	1	01	01	H0504_047_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											93.35	29	29	29				70.64	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0504	047	0	1	01	01	H0504_047_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											636.13	28						433.84	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	050	0	1	01	01	H0504_050_0	5			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	100	2	2			100				30		31								5.00	5.00	5.00					0.00	0.00	0.00							0.00																5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0504	050	0	1	01	01	H0504_050_0	5			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	050	0	1	01	01	H0504_050_0	5			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											57.31	20	20	20				54.90	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H0504	050	0	1	01	01	H0504_050_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											103.55	25	25	25				73.27	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H0504	050	0	1	01	01	H0504_050_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											617.67	29						517.79	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0523	022	0	1	01	01	H0523_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																														
H0523	022	0	1	01	01	H0523_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																														
H0523	022	0	1	01	01	H0523_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											70.57	24	24	24				96.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	022	0	1	01	01	H0523_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											42.16	25	25	25				50.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	022	0	1	01	01	H0523_022_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											462.89	25						609.66	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	25			25			25			25			25		25
H0523	065	0	1	01	01	H0523_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																														
H0523	065	0	1	01	01	H0523_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																														
H0523	065	0	1	01	01	H0523_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											69.06	24	24	24				99.56	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	065	0	1	01	01	H0523_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											39.76	25	25	25				48.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	065	0	1	01	01	H0523_065_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											570.71	25						621.47	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	25			25			25			25			25		25
H0523	070	0	1	02	01	H0523_070_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	070	0	1	02	01	H0523_070_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																														
H0523	070	0	1	02	01	H0523_070_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											78.06	25	25	25				103.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	070	0	1	02	01	H0523_070_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											47.42	26	26	26				56.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	070	0	1	02	01	H0523_070_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											619.65	29						732.38	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0523	073	0	1	02	01	H0523_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																														
H0523	073	0	1	02	01	H0523_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																														
H0523	073	0	1	02	01	H0523_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											80.65	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	073	0	1	02	01	H0523_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											42.47	25	25	25				51.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	073	0	1	02	01	H0523_073_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											499.96	25						695.66	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	25			25			25			25			25		25
H0523	074	0	1	02	01	H0523_074_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	074	0	1	02	01	H0523_074_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.20	22	22	22				87.89	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0523	074	0	1	02	01	H0523_074_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.18	25	25	25				51.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	074	0	1	02	01	H0523_074_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.41	25						599.21	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	25			25			25			25			25		25
H0523	075	0	1	02	01	H0523_075_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	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	075	0	1	02	01	H0523_075_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											91.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	075	0	1	02	01	H0523_075_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.91	26	26	26				51.47	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	075	0	1	02	01	H0523_075_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											659.39	29						674.10	29												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	25			25			25			25			25		25
H0523	083	0	1	02	01	H0523_083_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	083	0	1	02	01	H0523_083_0	2			Generic	4	01	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	083	0	1	02	01	H0523_083_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.72	25	25	25				88.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	083	0	1	02	01	H0523_083_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.00	26	26	26				48.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	083	0	1	02	01	H0523_083_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											607.88	29						712.47	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0523	085	0	1	02	01	H0523_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																														
H0523	085	0	1	02	01	H0523_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																														
H0523	085	0	1	02	01	H0523_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											63.64	24	24	24				90.55	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	085	0	1	02	01	H0523_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											39.03	25	25	25				48.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	085	0	1	02	01	H0523_085_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											532.38	25						623.76	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	25			25			25			25			25		25
H0523	086	0	1	01	01	H0523_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																														
H0523	086	0	1	01	01	H0523_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					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	086	0	1	01	01	H0523_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											63.70	25	25	25				89.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	086	0	1	01	01	H0523_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											39.07	26	26	26				48.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	086	0	1	01	01	H0523_086_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											610.13	29						716.59	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0523	088	0	1	02	01	H0523_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																														
H0523	088	0	1	02	01	H0523_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	088	0	1	02	01	H0523_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											63.59	24	24	24				90.12	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	088	0	1	02	01	H0523_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											38.93	25	25	25				48.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	088	0	1	02	01	H0523_088_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											529.71	25						619.08	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	25			25			25			25			25		25
H0523	089	0	1	01	01	H0523_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																														
H0523	089	0	1	01	01	H0523_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																														
H0523	089	0	1	01	01	H0523_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											63.65	24	24	24				90.69	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	089	0	1	01	01	H0523_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											39.07	25	25	25				48.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	089	0	1	01	01	H0523_089_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.25	25						625.30	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	25			25			25			25			25		25
H0523	091	0	1	01	01	H0523_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																														
H0523	091	0	1	01	01	H0523_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																														
H0523	091	0	1	01	01	H0523_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											63.95	24	24	24				92.91	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	091	0	1	01	01	H0523_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											39.70	25	25	25				47.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	091	0	1	01	01	H0523_091_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											549.86	25						656.70	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	25			25			25			25			25		25
H0523	092	0	1	01	01	H0523_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																														
H0523	092	0	1	01	01	H0523_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																														
H0523	092	0	1	01	01	H0523_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											63.68	24	24	24				90.89	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0523	092	0	1	01	01	H0523_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											39.12	25	25	25				48.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0523	092	0	1	01	01	H0523_092_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											534.59	25						627.70	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	25			25			25			25			25		25
H0524	003	0	1	01	01	H0524_003_0	4			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	0	0	0				0	0	0				0		0
H0524	003	0	1	01	01	H0524_003_0	4			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		0.17			0.17			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	25	25	25				25	25	25				25		25
H0524	003	0	1	01	01	H0524_003_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			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, Vaccines	35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	003	0	1	01	01	H0524_003_0	4			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	003	0	1	01	01	H0524_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					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	003	0	1	01	01	H0524_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	008	0	1	01	01	H0524_008_0	5			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	0	0	0				0	0	0				0		0
H0524	008	0	1	01	01	H0524_008_0	5			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	25	25	25				25	25	25				25		25
H0524	008	0	1	01	01	H0524_008_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	008	0	1	01	01	H0524_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	008	0	1	01	01	H0524_008_0	5			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	25	25	25				25	25	25				25		25
H0524	008	0	1	01	01	H0524_008_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	013	0	1	01	01	H0524_013_0	5			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	0	0	0				0	0	0				0		0
H0524	013	0	1	01	01	H0524_013_0	5			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	25	25	25				25	25	25				25		25
H0524	013	0	1	01	01	H0524_013_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	013	0	1	01	01	H0524_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	013	0	1	01	01	H0524_013_0	5			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	25	25	25				25	25	25				25		25
H0524	013	0	1	01	01	H0524_013_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	015	0	1	01	01	H0524_015_0	5			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	0	0	0				0	0	0				0		0
H0524	015	0	1	01	01	H0524_015_0	5			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	0	0	0				0	0	0				0		0
H0524	015	0	1	01	01	H0524_015_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	015	0	1	01	01	H0524_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	015	0	1	01	01	H0524_015_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	015	0	1	01	01	H0524_015_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	031	0	1	01	01	H0524_031_0	5			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	0	0	0				0	0	0				0		0
H0524	031	0	1	01	01	H0524_031_0	5			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	25	25	25				25	25	25				25		25
H0524	031	0	1	01	01	H0524_031_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	031	0	1	01	01	H0524_031_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	031	0	1	01	01	H0524_031_0	5			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	25	25	25				25	25	25				25		25
H0524	031	0	1	01	01	H0524_031_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	032	0	1	01	01	H0524_032_0	5			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	0	0	0				0	0	0				0		0
H0524	032	0	1	01	01	H0524_032_0	5			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	25	25	25				25	25	25				25		25
H0524	032	0	1	01	01	H0524_032_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	032	0	1	01	01	H0524_032_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	032	0	1	01	01	H0524_032_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	032	0	1	01	01	H0524_032_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	033	0	1	01	01	H0524_033_0	5			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	0	0	0				0	0	0				0		0
H0524	033	0	1	01	01	H0524_033_0	5			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	25	25	25				25	25	25				25		25
H0524	033	0	1	01	01	H0524_033_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	033	0	1	01	01	H0524_033_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	033	0	1	01	01	H0524_033_0	5			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	25	25	25				25	25	25				25		25
H0524	033	0	1	01	01	H0524_033_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	034	0	1	01	01	H0524_034_0	5			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	0	0	0				0	0	0				0		0
H0524	034	0	1	01	01	H0524_034_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H0524	034	0	1	01	01	H0524_034_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	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00				15.00	30.00	30.00				15.00		15.00	25	25	25				25	25	25				25		25
H0524	034	0	1	01	01	H0524_034_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	034	0	1	01	01	H0524_034_0	5			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	25	25	25				25	25	25				25		25
H0524	034	0	1	01	01	H0524_034_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	035	0	1	01	01	H0524_035_0	5			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	0	0	0				0	0	0				0		0
H0524	035	0	1	01	01	H0524_035_0	5			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		0.17			0.17			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	25	25	25				25	25	25				25		25
H0524	035	0	1	01	01	H0524_035_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	035	0	1	01	01	H0524_035_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	035	0	1	01	01	H0524_035_0	5			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	25	25	25				25	25	25				25		25
H0524	035	0	1	01	01	H0524_035_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	036	0	1	01	01	H0524_036_0	5			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	0	0	0				0	0	0				0		0
H0524	036	0	1	01	01	H0524_036_0	5			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	0	0	0				0	0	0				0		0
H0524	036	0	1	01	01	H0524_036_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	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, Vaccines	35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	036	0	1	01	01	H0524_036_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	036	0	1	01	01	H0524_036_0	5			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	25	25	25				25	25	25				25		25
H0524	036	0	1	01	01	H0524_036_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	037	0	1	01	01	H0524_037_0	5			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	0	0	0				0	0	0				0		0
H0524	037	0	1	01	01	H0524_037_0	5			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	25	25	25				25	25	25				25		25
H0524	037	0	1	01	01	H0524_037_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	037	0	1	01	01	H0524_037_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	037	0	1	01	01	H0524_037_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	037	0	1	01	01	H0524_037_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	038	0	1	01	01	H0524_038_0	5			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	0	0	0				0	0	0				0		0
H0524	038	0	1	01	01	H0524_038_0	5			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		0.27			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	25	25	25				25	25	25				25		25
H0524	038	0	1	01	01	H0524_038_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	038	0	1	01	01	H0524_038_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	038	0	1	01	01	H0524_038_0	5			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	25	25	25				25	25	25				25		25
H0524	038	0	1	01	01	H0524_038_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	039	0	1	01	01	H0524_039_0	5			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	0	0	0				0	0	0				0		0
H0524	039	0	1	01	01	H0524_039_0	5			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	25	25	25				25	25	25				25		25
H0524	039	0	1	01	01	H0524_039_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	039	0	1	01	01	H0524_039_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	039	0	1	01	01	H0524_039_0	5			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	25	25	25				25	25	25				25		25
H0524	039	0	1	01	01	H0524_039_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	040	0	1	01	01	H0524_040_0	5			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	0	0	0				0	0	0				0		0
H0524	040	0	1	01	01	H0524_040_0	5			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	25	25	25				25	25	25				25		25
H0524	040	0	1	01	01	H0524_040_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	040	0	1	01	01	H0524_040_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	040	0	1	01	01	H0524_040_0	5			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	25	25	25				25	25	25				25		25
H0524	040	0	1	01	01	H0524_040_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	041	0	1	01	01	H0524_041_0	5			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	0	0	0				0	0	0				0		0
H0524	041	0	1	01	01	H0524_041_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	22.00	22.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	11.00	22.00	33.00				11.00	22.00	22.00				11.00		11.00	25	25	25				25	25	25				25		25
H0524	041	0	1	01	01	H0524_041_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	041	0	1	01	01	H0524_041_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	041	0	1	01	01	H0524_041_0	5			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	25	25	25				25	25	25				25		25
H0524	041	0	1	01	01	H0524_041_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	042	0	1	01	01	H0524_042_0	5			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	0	0	0				0	0	0				0		0
H0524	042	0	1	01	01	H0524_042_0	5			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	25	25	25				25	25	25				25		25
H0524	042	0	1	01	01	H0524_042_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	042	0	1	01	01	H0524_042_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	042	0	1	01	01	H0524_042_0	5			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	25	25	25				25	25	25				25		25
H0524	042	0	1	01	01	H0524_042_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	043	0	1	01	01	H0524_043_0	5			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			0.10	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	25	25	25				25	25	25				25		25
H0524	043	0	1	01	01	H0524_043_0	5			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	25	25	25				25	25	25				25		25
H0524	043	0	1	01	01	H0524_043_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	043	0	1	01	01	H0524_043_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	043	0	1	01	01	H0524_043_0	5			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	25	25	25				25	25	25				25		25
H0524	043	0	1	01	01	H0524_043_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	046	0	1	01	01	H0524_046_0	5			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			0.10	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	25	25	25				25	25	25				25		25
H0524	046	0	1	01	01	H0524_046_0	5			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	25	25	25				25	25	25				25		25
H0524	046	0	1	01	01	H0524_046_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	046	0	1	01	01	H0524_046_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	046	0	1	01	01	H0524_046_0	5			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	25	25	25				25	25	25				25		25
H0524	046	0	1	01	01	H0524_046_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	051	0	1	01	01	H0524_051_0	5			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			0.10	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	25	25	25				25	25	25				25		25
H0524	051	0	1	01	01	H0524_051_0	5			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	25	25	25				25	25	25				25		25
H0524	051	0	1	01	01	H0524_051_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	051	0	1	01	01	H0524_051_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	051	0	1	01	01	H0524_051_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	051	0	1	01	01	H0524_051_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	054	0	1	01	01	H0524_054_0	5			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	0	0	0				0	0	0				0		0
H0524	054	0	1	01	01	H0524_054_0	5			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	25	25	25				25	25	25				25		25
H0524	054	0	1	01	01	H0524_054_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	054	0	1	01	01	H0524_054_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	054	0	1	01	01	H0524_054_0	5			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	25	25	25				25	25	25				25		25
H0524	054	0	1	01	01	H0524_054_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	059	0	1	01	01	H0524_059_0	5			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	0	0	0				0	0	0				0		0
H0524	059	0	1	01	01	H0524_059_0	5			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	0	0	0				0	0	0				0		0
H0524	059	0	1	01	01	H0524_059_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				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, Vaccines	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	059	0	1	01	01	H0524_059_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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	25	25	25				25	25	25				25		25
H0524	059	0	1	01	01	H0524_059_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					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		35.00	25	25	25				25	25	25				25		25
H0524	059	0	1	01	01	H0524_059_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	060	0	1	01	01	H0524_060_0	5			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			0.10	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	0	0	0				0	0	0				0		0
H0524	060	0	1	01	01	H0524_060_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	9.00	18.00	27.00																			9.00	18.00	18.00																9.00				9.00		0.30			0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	4.00	8.00	12.00				4.00	8.00	8.00				4.00		4.00	25	25	25				25	25	25				25		25
H0524	060	0	1	01	01	H0524_060_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	060	0	1	01	01	H0524_060_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	060	0	1	01	01	H0524_060_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					28	28	28																		28	28	28															28			28								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	25	25	25				25	25	25				25		25
H0524	060	0	1	01	01	H0524_060_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	061	0	1	01	01	H0524_061_0	5			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	0	0	0				0	0	0				0		0
H0524	061	0	1	01	01	H0524_061_0	5			Generic	4	11	1	2	2	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			0.13	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	25	25	25				25	25	25				25		25
H0524	061	0	1	01	01	H0524_061_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	061	0	1	01	01	H0524_061_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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	25	25	25				25	25	25				25		25
H0524	061	0	1	01	01	H0524_061_0	5			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	25	25	25				25	25	25				25		25
H0524	061	0	1	01	01	H0524_061_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	062	0	1	01	01	H0524_062_0	5			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	0	0	0				0	0	0				0		0
H0524	062	0	1	01	01	H0524_062_0	5			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	0	0	0				0	0	0				0		0
H0524	062	0	1	01	01	H0524_062_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	062	0	1	01	01	H0524_062_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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	25	25	25				25	25	25				25		25
H0524	062	0	1	01	01	H0524_062_0	5			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	25	25	25				25	25	25				25		25
H0524	062	0	1	01	01	H0524_062_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	063	0	1	01	01	H0524_063_0	5			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	0	0	0				0	0	0				0		0
H0524	063	0	1	01	01	H0524_063_0	5			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	0	0	0				0	0	0				0		0
H0524	063	0	1	01	01	H0524_063_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				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, Vaccines	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	063	0	1	01	01	H0524_063_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	063	0	1	01	01	H0524_063_0	5			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	25	25	25				25	25	25				25		25
H0524	063	0	1	01	01	H0524_063_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	064	0	1	01	01	H0524_064_0	5			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			0.10	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	25	25	25				25	25	25				25		25
H0524	064	0	1	01	01	H0524_064_0	5			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	25	25	25				25	25	25				25		25
H0524	064	0	1	01	01	H0524_064_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H0524	064	0	1	01	01	H0524_064_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	064	0	1	01	01	H0524_064_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		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		35.00	25	25	25				25	25	25				25		25
H0524	064	0	1	01	01	H0524_064_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	065	0	1	01	01	H0524_065_0	5			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	0	0	0				0	0	0				0		0
H0524	065	0	1	01	01	H0524_065_0	5			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	0	0	0				0	0	0				0		0
H0524	065	0	1	01	01	H0524_065_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	065	0	1	01	01	H0524_065_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	85.00	170.00	255.00																			85.00	170.00	170.00																85.00				85.00		2.83			2.83			2.74	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	25	25	25				25	25	25				25		25
H0524	065	0	1	01	01	H0524_065_0	5			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	25	25	25				25	25	25				25		25
H0524	065	0	1	01	01	H0524_065_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	078	0	1	01	01	H0524_078_0	5			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	0	0	0				0	0	0				0		0
H0524	078	0	1	01	01	H0524_078_0	5			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	0	0	0				0	0	0				0		0
H0524	078	0	1	01	01	H0524_078_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	078	0	1	01	01	H0524_078_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	100.00	200.00	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	078	0	1	01	01	H0524_078_0	5			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	25	25	25				25	25	25				25		25
H0524	078	0	1	01	01	H0524_078_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	081	0	1	01	01	H0524_081_0	5			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	0	0	0				0	0	0				0		0
H0524	081	0	1	01	01	H0524_081_0	5			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	0	0	0				0	0	0				0		0
H0524	081	0	1	01	01	H0524_081_0	5			Preferred Brand	4	11	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	25	25	25				25	25	25				25		25
H0524	081	0	1	01	01	H0524_081_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	081	0	1	01	01	H0524_081_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31					32	32	32																		32	32	32															32			32								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	25	25	25				25	25	25				25		25
H0524	081	0	1	01	01	H0524_081_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	082	0	1	01	01	H0524_082_0	5			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	0	0	0				0	0	0				0		0
H0524	082	0	1	01	01	H0524_082_0	5			Generic	4	11	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	6.00																3.00				3.00		0.10			0.10			0.10	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	25	25	25				25	25	25				25		25
H0524	082	0	1	01	01	H0524_082_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	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, Vaccines	35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	082	0	1	01	01	H0524_082_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	082	0	1	01	01	H0524_082_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		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		35.00	25	25	25				25	25	25				25		25
H0524	082	0	1	01	01	H0524_082_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0524	083	0	1	01	01	H0524_083_0	5			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	0	0	0				0	0	0				0		0
H0524	083	0	1	01	01	H0524_083_0	5			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				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	25	25	25				25	25	25				25		25
H0524	083	0	1	01	01	H0524_083_0	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	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, Vaccines	35.00	70.00	105.00				35.00	70.00	90.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	083	0	1	01	01	H0524_083_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0524	083	0	1	01	01	H0524_083_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				2	2	30	60	100				30		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		35.00	25	25	25				25	25	25				25		25
H0524	083	0	1	01	01	H0524_083_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H0543	013	0	1	02	01	H0543_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	1.00		3.00																											3.00						0.00				1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	013	0	1	02	01	H0543_013_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	013	0	1	02	01	H0543_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H0543	013	0	1	02	01	H0543_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	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	25						25			25			25		25
H0543	013	0	1	02	01	H0543_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H0543	019	0	1	02	01	H0543_019_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	019	0	1	02	01	H0543_019_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	019	0	1	02	01	H0543_019_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	019	0	1	02	01	H0543_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	019	0	1	02	01	H0543_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				429.00	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	25						25			25			25		25
H0543	035	0	1	02	01	H0543_035_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	035	0	1	02	01	H0543_035_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	035	0	1	02	01	H0543_035_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				31.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	035	0	1	02	01	H0543_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	035	0	1	02	01	H0543_035_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				403.00	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	25						25			25			25		25
H0543	060	0	1	02	01	H0543_060_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	1.00		3.00																											3.00						0.00				1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	060	0	1	02	01	H0543_060_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	060	0	1	02	01	H0543_060_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0543	060	0	1	02	01	H0543_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				93.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	060	0	1	02	01	H0543_060_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				377.00	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	25						25			25			25		25
H0543	086	0	1	02	01	H0543_086_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	086	0	1	02	01	H0543_086_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	086	0	1	02	01	H0543_086_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	086	0	1	02	01	H0543_086_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	086	0	1	02	01	H0543_086_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				408.00	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	25						25			25			25		25
H0543	140	0	1	02	01	H0543_140_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	140	0	1	02	01	H0543_140_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	140	0	1	02	01	H0543_140_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0543	140	0	1	02	01	H0543_140_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	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	25						25			25			25		25
H0543	140	0	1	02	01	H0543_140_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	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	25						25			25			25		25
H0543	145	0	1	02	01	H0543_145_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	1.00		3.00																											3.00						0.00				1.00				1.00		0.03						0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	145	0	1	02	01	H0543_145_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	145	0	1	02	01	H0543_145_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H0543	145	0	1	02	01	H0543_145_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	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	25						25			25			25		25
H0543	145	0	1	02	01	H0543_145_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H0543	151	0	1	02	01	H0543_151_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	151	0	1	02	01	H0543_151_0	4			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																														
H0543	151	0	1	02	01	H0543_151_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				33.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H0543	151	0	1	02	01	H0543_151_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				96.00	37																				37																	37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	151	0	1	02	01	H0543_151_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				460.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	152	0	1	02	01	H0543_152_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	152	0	1	02	01	H0543_152_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	152	0	1	02	01	H0543_152_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0543	152	0	1	02	01	H0543_152_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				99.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	152	0	1	02	01	H0543_152_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				413.00	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	25						25			25			25		25
H0543	166	0	1	02	01	H0543_166_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	166	0	1	02	01	H0543_166_0	4			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																														
H0543	166	0	1	02	01	H0543_166_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H0543	166	0	1	02	01	H0543_166_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				85.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	166	0	1	02	01	H0543_166_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	168	0	1	02	01	H0543_168_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	168	0	1	02	01	H0543_168_0	4			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																														
H0543	168	0	1	02	01	H0543_168_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				36.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H0543	168	0	1	02	01	H0543_168_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				100.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	168	0	1	02	01	H0543_168_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				413.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	169	0	1	02	01	H0543_169_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	169	0	1	02	01	H0543_169_0	4			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																														
H0543	169	0	1	02	01	H0543_169_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				35.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H0543	169	0	1	02	01	H0543_169_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				98.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	169	0	1	02	01	H0543_169_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				429.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	170	0	1	02	01	H0543_170_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	170	0	1	02	01	H0543_170_0	4			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																														
H0543	170	0	1	02	01	H0543_170_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H0543	170	0	1	02	01	H0543_170_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				93.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	170	0	1	02	01	H0543_170_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				414.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	188	0	1	02	01	H0543_188_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	188	0	1	02	01	H0543_188_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	188	0	1	02	01	H0543_188_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	188	0	1	02	01	H0543_188_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	188	0	1	02	01	H0543_188_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				366.00	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	25						25			25			25		25
H0543	189	0	1	02	01	H0543_189_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	189	0	1	02	01	H0543_189_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	189	0	1	02	01	H0543_189_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0543	189	0	1	02	01	H0543_189_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	189	0	1	02	01	H0543_189_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				397.00	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	25						25			25			25		25
H0543	191	0	1	02	01	H0543_191_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	191	0	1	02	01	H0543_191_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	191	0	1	02	01	H0543_191_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				30.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0543	191	0	1	02	01	H0543_191_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	191	0	1	02	01	H0543_191_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	193	0	1	02	01	H0543_193_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	193	0	1	02	01	H0543_193_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	193	0	1	02	01	H0543_193_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H0543	193	0	1	02	01	H0543_193_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	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	25						25			25			25		25
H0543	193	0	1	02	01	H0543_193_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H0543	204	0	1	02	01	H0543_204_0	4			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	4			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			0.67	0.00				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	204	0	1	02	01	H0543_204_0	4			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		100	2	2						100	30		31											53.00	23		23				55.00	23		23												23						23			23			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	23		23	23		23			23			23	23		23
H0543	204	0	1	02	01	H0543_204_0	4			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	25						101.00	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	25			25			25			25			25		25
H0543	204	0	1	02	01	H0543_204_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											410.00	29						384.00	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0543	214	0	1	02	01	H0543_214_0	5			Preferred Generic	4	01	1	2	1	1	110		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																														
H0543	214	0	1	02	01	H0543_214_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	214	0	1	02	01	H0543_214_0	5			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	22		22						22				22		22
H0543	214	0	1	02	01	H0543_214_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				79.00	47																				47																	47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	214	0	1	02	01	H0543_214_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				449.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	217	0	1	02	01	H0543_217_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	217	0	1	02	01	H0543_217_0	4			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																														
H0543	217	0	1	02	01	H0543_217_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	22		22						22				22		22
H0543	217	0	1	02	01	H0543_217_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				89.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	217	0	1	02	01	H0543_217_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				458.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	218	0	1	02	01	H0543_218_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	218	0	1	02	01	H0543_218_0	4			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																														
H0543	218	0	1	02	01	H0543_218_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	22		22						22				22		22
H0543	218	0	1	02	01	H0543_218_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				81.00	49																				49																	49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	218	0	1	02	01	H0543_218_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				463.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	219	0	1	02	01	H0543_219_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	219	0	1	02	01	H0543_219_0	4			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																														
H0543	219	0	1	02	01	H0543_219_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	22		22						22				22		22
H0543	219	0	1	02	01	H0543_219_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				78.00	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	219	0	1	02	01	H0543_219_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				446.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	220	0	1	02	01	H0543_220_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	220	0	1	02	01	H0543_220_0	4			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																														
H0543	220	0	1	02	01	H0543_220_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H0543	220	0	1	02	01	H0543_220_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				93.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	220	0	1	02	01	H0543_220_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				427.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	221	0	1	02	01	H0543_221_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	221	0	1	02	01	H0543_221_0	4			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																														
H0543	221	0	1	02	01	H0543_221_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				38.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H0543	221	0	1	02	01	H0543_221_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				90.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	221	0	1	02	01	H0543_221_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				430.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	222	0	1	02	01	H0543_222_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	222	0	1	02	01	H0543_222_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	222	0	1	02	01	H0543_222_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	222	0	1	02	01	H0543_222_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	222	0	1	02	01	H0543_222_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				408.00	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	25						25			25			25		25
H0543	225	0	1	02	01	H0543_225_0	5			Preferred Generic	4	01	1	2	1	1	110		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																														
H0543	225	0	1	02	01	H0543_225_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	225	0	1	02	01	H0543_225_0	5			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H0543	225	0	1	02	01	H0543_225_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				93.00	35																				35																	35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	225	0	1	02	01	H0543_225_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	226	0	1	02	01	H0543_226_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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	226	0	1	02	01	H0543_226_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00			0.00	0.00		0.00	20		20						20			20	20		20
H0543	226	0	1	02	01	H0543_226_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	226	0	1	02	01	H0543_226_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				483.00	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	25						25			25			25		25
H0543	232	0	1	02	01	H0543_232_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	232	0	1	02	01	H0543_232_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	232	0	1	02	01	H0543_232_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0543	232	0	1	02	01	H0543_232_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	232	0	1	02	01	H0543_232_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	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	25						25			25			25		25
H0543	236	0	1	02	01	H0543_236_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	236	0	1	02	01	H0543_236_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	236	0	1	02	01	H0543_236_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0543	236	0	1	02	01	H0543_236_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	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	25						25			25			25		25
H0543	236	0	1	02	01	H0543_236_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H0543	237	0	1	02	01	H0543_237_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	237	0	1	02	01	H0543_237_0	10			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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	237	0	1	02	01	H0543_237_0	10			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0543	237	0	1	02	01	H0543_237_0	10			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				98.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0543	237	0	1	02	01	H0543_237_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	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	25						25			25			25		25
H0543	238	0	1	02	01	H0543_238_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	238	0	1	02	01	H0543_238_0	10			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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	238	0	1	02	01	H0543_238_0	10			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0543	238	0	1	02	01	H0543_238_0	10			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	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	25						25			25			25		25
H0543	238	0	1	02	01	H0543_238_0	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				366.00	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	25						25			25			25		25
H0543	251	0	1	02	01	H0543_251_0	5			Preferred Generic	4	01	1	2	1	1	110		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																														
H0543	251	0	1	02	01	H0543_251_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	251	0	1	02	01	H0543_251_0	5			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0543	251	0	1	02	01	H0543_251_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				85.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	251	0	1	02	01	H0543_251_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	254	0	1	02	01	H0543_254_0	5			Preferred Generic	4	01	1	2	1	1	110		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																														
H0543	254	0	1	02	01	H0543_254_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0543	254	0	1	02	01	H0543_254_0	5			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				39.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0543	254	0	1	02	01	H0543_254_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				93.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	254	0	1	02	01	H0543_254_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				429.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	255	0	1	02	01	H0543_255_0	13			Preferred Generic	4	01	1	2	1	1	110		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																														
H0543	255	0	1	02	01	H0543_255_0	13			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																														
H0543	255	0	1	02	01	H0543_255_0	13			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				38.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H0543	255	0	1	02	01	H0543_255_0	13			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				96.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0543	255	0	1	02	01	H0543_255_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				415.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0544	002	0	1	02	01	H0544_002_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	002	0	1	02	01	H0544_002_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.00	25	25	25				120.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H0544	002	0	1	02	01	H0544_002_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.00	30	30	30				47.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	002	0	1	02	01	H0544_002_0	4			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																														
H0544	002	0	1	02	01	H0544_002_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	004	0	1	02	01	H0544_004_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	004	0	1	02	01	H0544_004_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					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	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H0544	004	0	1	02	01	H0544_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											86.00	30	30	30				44.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	004	0	1	02	01	H0544_004_0	4			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																														
H0544	004	0	1	02	01	H0544_004_0	4			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	0	0	0	0	0	0	0	0	0				0		0
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	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				77.00	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
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				61.00	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		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								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	0	0	0				0	0	0				0		0
H0544	010	0	1	02	01	H0544_010_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	010	0	1	02	01	H0544_010_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					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	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H0544	010	0	1	02	01	H0544_010_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											71.00	30	30	30				38.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	010	0	1	02	01	H0544_010_0	4			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																														
H0544	010	0	1	02	01	H0544_010_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	014	0	1	02	01	H0544_014_0	4			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	014	0	1	02	01	H0544_014_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					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	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H0544	014	0	1	02	01	H0544_014_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	30	30	30				42.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	014	0	1	02	01	H0544_014_0	4			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																														
H0544	014	0	1	02	01	H0544_014_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	015	0	1	02	01	H0544_015_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	015	0	1	02	01	H0544_015_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.00	25	25	25				89.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H0544	015	0	1	02	01	H0544_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		34											84.00	30	30	30				43.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	015	0	1	02	01	H0544_015_0	4			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																														
H0544	015	0	1	02	01	H0544_015_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	019	0	1	02	01	H0544_019_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	019	0	1	02	01	H0544_019_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					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	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H0544	019	0	1	02	01	H0544_019_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											42.00	30	30	30				35.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	019	0	1	02	01	H0544_019_0	4			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																														
H0544	019	0	1	02	01	H0544_019_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	020	0	1	02	01	H0544_020_0	4			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	020	0	1	02	01	H0544_020_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	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	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.00	25	25	25				91.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H0544	020	0	1	02	01	H0544_020_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.00	30	30	30				65.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	020	0	1	02	01	H0544_020_0	4			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																														
H0544	020	0	1	02	01	H0544_020_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H0544	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	75.00				25.00		25.00	25	25	25	25	25	25	25	25	25				25		25
H0544	056	0	1	02	01	H0544_056_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											21.00	25	25	25				12.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H0544	056	0	1	02	01	H0544_056_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	056	0	1	02	01	H0544_056_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																														
H0544	058	0	1	02	01	H0544_058_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	058	0	1	02	01	H0544_058_0	5			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				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	058	0	1	02	01	H0544_058_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											56.00	30	30	30				42.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	058	0	1	02	01	H0544_058_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	061	0	1	02	01	H0544_061_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																														
H0544	061	0	1	02	01	H0544_061_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											91.00	25	25	25				104.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	061	0	1	02	01	H0544_061_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											34.00	30	30	30				40.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	061	0	1	02	01	H0544_061_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	062	0	1	02	01	H0544_062_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																														
H0544	062	0	1	02	01	H0544_062_0	5			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																														
H0544	062	0	1	02	01	H0544_062_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	20	20	20				54.00	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	20	20	20	15	15	15	15	15	15				20		20
H0544	062	0	1	02	01	H0544_062_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											23.00	30	30	30				17.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	062	0	1	02	01	H0544_062_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																														
H0544	063	0	1	02	01	H0544_063_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																														
H0544	063	0	1	02	01	H0544_063_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	063	0	1	02	01	H0544_063_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											68.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	063	0	1	02	01	H0544_063_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											48.00	30	30	30				34.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	063	0	1	02	01	H0544_063_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	064	0	1	02	01	H0544_064_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	064	0	1	02	01	H0544_064_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	064	0	1	02	01	H0544_064_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.00	25	25	25				84.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H0544	064	0	1	02	01	H0544_064_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											36.00	30	30	30				19.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	064	0	1	02	01	H0544_064_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	064	0	1	02	01	H0544_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	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	065	0	1	02	01	H0544_065_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	065	0	1	02	01	H0544_065_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	065	0	1	02	01	H0544_065_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											34.00	30	30	30				16.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	065	0	1	02	01	H0544_065_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	065	0	1	02	01	H0544_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	066	0	1	02	01	H0544_066_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.00	25	25	25				96.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H0544	066	0	1	02	01	H0544_066_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											39.00	30	30	30				23.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	066	0	1	02	01	H0544_066_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	069	0	1	02	01	H0544_069_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	069	0	1	02	01	H0544_069_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											86.00	25	25	25				99.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H0544	069	0	1	02	01	H0544_069_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											46.00	30	30	30				42.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	069	0	1	02	01	H0544_069_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	091	0	1	02	01	H0544_091_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																														
H0544	091	0	1	02	01	H0544_091_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	091	0	1	02	01	H0544_091_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	091	0	1	02	01	H0544_091_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.00	30	30	30				37.00	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	25	25	25	25	25	25	25	25	25				25		25
H0544	091	0	1	02	01	H0544_091_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0544	095	0	1	02	01	H0544_095_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	095	0	1	02	01	H0544_095_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0544	095	0	1	02	01	H0544_095_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											39.00	20	20	20				66.00	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	20	20	20	20	20	20	20	20	20				20		20
H0544	095	0	1	02	01	H0544_095_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											29.00	30	30	30				12.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	095	0	1	02	01	H0544_095_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	095	0	1	02	01	H0544_095_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																														
H0544	096	0	1	02	01	H0544_096_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																														
H0544	096	0	1	02	01	H0544_096_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																														
H0544	096	0	1	02	01	H0544_096_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	096	0	1	02	01	H0544_096_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											24.00	25	25	25				21.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	096	0	1	02	01	H0544_096_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																														
H0544	098	0	1	02	01	H0544_098_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																														
H0544	098	0	1	02	01	H0544_098_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																														
H0544	098	0	1	02	01	H0544_098_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	098	0	1	02	01	H0544_098_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											24.00	25	25	25				24.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	098	0	1	02	01	H0544_098_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																														
H0544	108	0	1	02	01	H0544_108_0	5			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	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																														
H0544	108	0	1	02	01	H0544_108_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	108	0	1	02	01	H0544_108_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											40.00	25	25	25				19.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0544	108	0	1	02	01	H0544_108_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																														
H0562	012	0	1	01	01	H0562_012_0	11			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	012	0	1	01	01	H0562_012_0	11			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	012	0	1	01	01	H0562_012_0	11			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.43	25	25	25				122.43	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	012	0	1	01	01	H0562_012_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											92.28	34	34	34				89.57	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	012	0	1	01	01	H0562_012_0	11			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	012	0	1	01	01	H0562_012_0	11			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	092	0	1	01	01	H0562_092_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	092	0	1	01	01	H0562_092_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.36	25	25	25				93.36	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	092	0	1	01	01	H0562_092_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											44.96	39	39	39				44.96	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	092	0	1	01	01	H0562_092_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								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		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0		0	0		0	0	0		0
H0562	097	0	1	01	01	H0562_097_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	097	0	1	01	01	H0562_097_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	097	0	1	01	01	H0562_097_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											102.18	25	25	25				102.18	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	097	0	1	01	01	H0562_097_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.51	35	35	35				98.51	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	097	0	1	01	01	H0562_097_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	097	0	1	01	01	H0562_097_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	125	0	1	01	01	H0562_125_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	125	0	1	01	01	H0562_125_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											111.29	25	25	25				111.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	125	0	1	01	01	H0562_125_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.58	33	33	33				95.59	32	32	32											33	33					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	125	0	1	01	01	H0562_125_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	125	0	1	01	01	H0562_125_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	126	0	1	01	01	H0562_126_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	126	0	1	01	01	H0562_126_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											109.58	25	25	25				109.58	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	126	0	1	01	01	H0562_126_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											76.58	37	37	37				76.58	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	126	0	1	01	01	H0562_126_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	126	0	1	01	01	H0562_126_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	133	0	1	01	01	H0562_133_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	133	0	1	01	01	H0562_133_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.65	25	25	25				120.65	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	133	0	1	01	01	H0562_133_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											53.09	36	36	36				51.62	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	133	0	1	01	01	H0562_133_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	133	0	1	01	01	H0562_133_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	136	0	1	01	01	H0562_136_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	136	0	1	01	01	H0562_136_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.76	25	25	25				99.76	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	136	0	1	01	01	H0562_136_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.69	36	36	36				77.47	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	136	0	1	01	01	H0562_136_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	136	0	1	01	01	H0562_136_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	137	0	1	01	01	H0562_137_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	137	0	1	01	01	H0562_137_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											110.29	25	25	25				110.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	137	0	1	01	01	H0562_137_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											61.87	40	40	40				60.32	39	39	39											40	40					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	137	0	1	01	01	H0562_137_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	137	0	1	01	01	H0562_137_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	138	0	1	01	01	H0562_138_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0562	138	0	1	01	01	H0562_138_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0562	138	0	1	01	01	H0562_138_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.95	25	25	25				93.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	138	0	1	01	01	H0562_138_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											55.77	35	35	35				55.77	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0562	138	0	1	01	01	H0562_138_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0562	138	0	1	01	01	H0562_138_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0		0	0		0	0	0		0
H0571	001	0	1	01	01	H0571_001_0	9			Preferred Generic	4	11	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	9			Generic	4	11	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								7.00	14.00	21.00					0.00	0.00	0.00							14.00																	7.00			7.00			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			14.00				7.00		7.00	25	25	25	25	25	25			25				25		25
H0571	001	0	1	01	01	H0571_001_0	9			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								45.00	90.00	135.00					45.00	90.00	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			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0571	001	0	1	01	01	H0571_001_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								100.00	200.00	300.00					100.00	200.00	200.00							200.00																	100.00			100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	70.00			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0571	001	0	1	01	01	H0571_001_0	9			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											1230.91	33						379.71	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0571	005	0	1	01	01	H0571_005_0	9		N	Preferred Generic	4	11	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0571	005	0	1	01	01	H0571_005_0	9		N	Generic	4	11	1	1	2	1	111		10	100		1	30	60	90				1	2			90					14	31				20.17	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	25	25	25						25				25		25
H0571	005	0	1	01	01	H0571_005_0	9		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				1	2			90					14	31				130.84	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	25	25	25						25				25		25
H0571	005	0	1	01	01	H0571_005_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				1	2			90					14	31				49.91	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	25	25	25						25				25		25
H0571	005	0	1	01	01	H0571_005_0	9		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							14	31				892.08	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0571	007	0	1	01	01	H0571_007_0	10			Preferred Generic	4	11	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	007	0	1	01	01	H0571_007_0	10			Generic	4	11	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								7.00	14.00	21.00					0.00	0.00	0.00							14.00																	7.00			7.00			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			14.00				7.00		7.00	25	25	25	25	25	25			25				25		25
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								47.00	94.00	141.00					47.00	94.00	94.00							94.00																	47.00			47.00			1.57	1.57				1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	70.00			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
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								100.00	200.00	300.00					100.00	200.00	200.00							200.00																	100.00			100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	70.00			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
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											634.89	33						589.94	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0571	010	0	1	01	01	H0571_010_0	9			Preferred Generic	4	11	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	9			Generic	4	11	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								7.00	14.00	21.00					0.00	0.00	0.00							14.00																	7.00			7.00			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			14.00				7.00		7.00	25	25	25	0	0	0			25				25		25
H0571	010	0	1	01	01	H0571_010_0	9			Preferred Brand	4	11	1	2	3	1		111	10	100		1				30	60	90	1	2			90					14	31								45.00	90.00	135.00					45.00	90.00	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			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0571	010	0	1	01	01	H0571_010_0	9			Non-Preferred Drug	4	11	1	2	4	1		111	10	100		1				30	60	90	1	2			90					14	31								100.00	200.00	300.00					100.00	200.00	200.00							200.00																	100.00			100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	70.00			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
H0571	010	0	1	01	01	H0571_010_0	9			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							14	31											761.84	33						649.62	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0571	011	0	1	01	01	H0571_011_0	10			Preferred Generic	4	11	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	011	0	1	01	01	H0571_011_0	10			Generic	4	11	1	2	2	1		111	10	100		1				30	60	90	1	2			90					14	31								7.00	14.00	21.00					0.00	0.00	0.00							14.00																	7.00			7.00			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			14.00				7.00		7.00	25	25	25	0	0	0			25				25		25
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								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	70.00			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
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								95.00	190.00	285.00					95.00	190.00	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			70.00				35.00		35.00	25	25	25	25	25	25			25				25		25
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											635.19	33						642.90	33						33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	007	0	1	02	01	H0609_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	007	0	1	02	01	H0609_007_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	007	0	1	02	01	H0609_007_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	007	0	1	02	01	H0609_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	007	0	1	02	01	H0609_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				430.00	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	25						25			25			25		25
H0609	012	0	1	02	01	H0609_012_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	012	0	1	02	01	H0609_012_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	012	0	1	02	01	H0609_012_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	012	0	1	02	01	H0609_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				100.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	012	0	1	02	01	H0609_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H0609	025	0	1	02	01	H0609_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	025	0	1	02	01	H0609_025_0	4			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																														
H0609	025	0	1	02	01	H0609_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				41.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0609	025	0	1	02	01	H0609_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				99.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	025	0	1	02	01	H0609_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				437.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	026	0	1	02	01	H0609_026_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	026	0	1	02	01	H0609_026_0	4			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																														
H0609	026	0	1	02	01	H0609_026_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				44.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H0609	026	0	1	02	01	H0609_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				90.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	026	0	1	02	01	H0609_026_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				422.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	027	0	1	02	01	H0609_027_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	027	0	1	02	01	H0609_027_0	4			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																														
H0609	027	0	1	02	01	H0609_027_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				44.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0609	027	0	1	02	01	H0609_027_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				92.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	027	0	1	02	01	H0609_027_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				398.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	028	0	1	02	01	H0609_028_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	028	0	1	02	01	H0609_028_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	028	0	1	02	01	H0609_028_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	028	0	1	02	01	H0609_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	028	0	1	02	01	H0609_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				480.00	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	25						25			25			25		25
H0609	031	0	1	02	01	H0609_031_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	031	0	1	02	01	H0609_031_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	031	0	1	02	01	H0609_031_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H0609	031	0	1	02	01	H0609_031_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	031	0	1	02	01	H0609_031_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				400.00	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	25						25			25			25		25
H0609	032	0	1	02	01	H0609_032_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	032	0	1	02	01	H0609_032_0	4			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																														
H0609	032	0	1	02	01	H0609_032_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				39.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0609	032	0	1	02	01	H0609_032_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				85.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	032	0	1	02	01	H0609_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				338.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	033	0	1	02	01	H0609_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	033	0	1	02	01	H0609_033_0	4			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																														
H0609	033	0	1	02	01	H0609_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				44.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H0609	033	0	1	02	01	H0609_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				91.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	033	0	1	02	01	H0609_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	034	1	1	02	01	H0609_034_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	034	1	1	02	01	H0609_034_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	034	1	1	02	01	H0609_034_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	034	1	1	02	01	H0609_034_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	034	1	1	02	01	H0609_034_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				342.00	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	25						25			25			25		25
H0609	034	2	1	02	01	H0609_034_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	034	2	1	02	01	H0609_034_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	034	2	1	02	01	H0609_034_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	034	2	1	02	01	H0609_034_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	034	2	1	02	01	H0609_034_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				342.00	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	25						25			25			25		25
H0609	036	1	1	02	01	H0609_036_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	036	1	1	02	01	H0609_036_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	036	1	1	02	01	H0609_036_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	036	1	1	02	01	H0609_036_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	036	1	1	02	01	H0609_036_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
H0609	036	2	1	02	01	H0609_036_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	036	2	1	02	01	H0609_036_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	036	2	1	02	01	H0609_036_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	036	2	1	02	01	H0609_036_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	036	2	1	02	01	H0609_036_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
H0609	037	0	1	02	01	H0609_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	037	0	1	02	01	H0609_037_0	4			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																														
H0609	037	0	1	02	01	H0609_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				63.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H0609	037	0	1	02	01	H0609_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				68.00	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	037	0	1	02	01	H0609_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	038	0	1	02	01	H0609_038_0	4			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	4			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	4			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		100	2	2						100	30		31											42.00	18		18				46.00	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	18		18	18		18			18			18	18		18
H0609	038	0	1	02	01	H0609_038_0	4			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											83.00	37						97.00	37												37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0609	038	0	1	02	01	H0609_038_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											395.00	30						419.00	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	25			25			25			25			25		25
H0609	040	0	1	02	01	H0609_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	040	0	1	02	01	H0609_040_0	4			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																														
H0609	040	0	1	02	01	H0609_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H0609	040	0	1	02	01	H0609_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				99.00	34																				34																	34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	040	0	1	02	01	H0609_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	042	0	1	02	01	H0609_042_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	042	0	1	02	01	H0609_042_0	4			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																														
H0609	042	0	1	02	01	H0609_042_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				63.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H0609	042	0	1	02	01	H0609_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				63.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	042	0	1	02	01	H0609_042_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				387.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	043	0	1	02	01	H0609_043_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	043	0	1	02	01	H0609_043_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	043	0	1	02	01	H0609_043_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H0609	043	0	1	02	01	H0609_043_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	043	0	1	02	01	H0609_043_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				428.00	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	25						25			25			25		25
H0609	044	0	1	02	01	H0609_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	044	0	1	02	01	H0609_044_0	4			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																														
H0609	044	0	1	02	01	H0609_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H0609	044	0	1	02	01	H0609_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	044	0	1	02	01	H0609_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	045	0	1	02	01	H0609_045_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	045	0	1	02	01	H0609_045_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	045	0	1	02	01	H0609_045_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	045	0	1	02	01	H0609_045_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	045	0	1	02	01	H0609_045_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				432.00	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	25						25			25			25		25
H0609	046	0	1	02	01	H0609_046_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	046	0	1	02	01	H0609_046_0	4			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																														
H0609	046	0	1	02	01	H0609_046_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H0609	046	0	1	02	01	H0609_046_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				86.00	37																				37																	37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	046	0	1	02	01	H0609_046_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	047	0	1	02	01	H0609_047_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	047	0	1	02	01	H0609_047_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	047	0	1	02	01	H0609_047_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				58.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H0609	047	0	1	02	01	H0609_047_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	047	0	1	02	01	H0609_047_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				431.00	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	25						25			25			25		25
H0609	048	0	1	02	01	H0609_048_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	048	0	1	02	01	H0609_048_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	048	0	1	02	01	H0609_048_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	048	0	1	02	01	H0609_048_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				97.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	048	0	1	02	01	H0609_048_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H0609	049	0	1	02	01	H0609_049_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	049	0	1	02	01	H0609_049_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	049	0	1	02	01	H0609_049_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H0609	049	0	1	02	01	H0609_049_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	049	0	1	02	01	H0609_049_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	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	25						25			25			25		25
H0609	050	0	1	02	01	H0609_050_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	050	0	1	02	01	H0609_050_0	4			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																														
H0609	050	0	1	02	01	H0609_050_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	15		15						15				15		15
H0609	050	0	1	02	01	H0609_050_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				94.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	050	0	1	02	01	H0609_050_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				407.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	051	0	1	02	01	H0609_051_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	051	0	1	02	01	H0609_051_0	4			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						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	051	0	1	02	01	H0609_051_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0609	051	0	1	02	01	H0609_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	051	0	1	02	01	H0609_051_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				392.00	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	25						25			25			25		25
H0609	052	0	1	02	01	H0609_052_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0609	052	0	1	02	01	H0609_052_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	052	0	1	02	01	H0609_052_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H0609	052	0	1	02	01	H0609_052_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	052	0	1	02	01	H0609_052_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	054	0	1	02	01	H0609_054_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	054	0	1	02	01	H0609_054_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	054	0	1	02	01	H0609_054_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0609	054	0	1	02	01	H0609_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	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	25						25			25			25		25
H0609	054	0	1	02	01	H0609_054_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
H0609	058	0	1	02	01	H0609_058_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	058	0	1	02	01	H0609_058_0	4			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																														
H0609	058	0	1	02	01	H0609_058_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				70.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H0609	058	0	1	02	01	H0609_058_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				82.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	058	0	1	02	01	H0609_058_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				416.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	059	0	1	02	01	H0609_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	059	0	1	02	01	H0609_059_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	059	0	1	02	01	H0609_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0609	059	0	1	02	01	H0609_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	059	0	1	02	01	H0609_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H0609	060	0	1	02	01	H0609_060_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	060	0	1	02	01	H0609_060_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	060	0	1	02	01	H0609_060_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0609	060	0	1	02	01	H0609_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	060	0	1	02	01	H0609_060_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H0609	061	0	1	02	01	H0609_061_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	061	0	1	02	01	H0609_061_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	061	0	1	02	01	H0609_061_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	061	0	1	02	01	H0609_061_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	061	0	1	02	01	H0609_061_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
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	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	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	1	3	1	110		01	100		1	30		100				2	2			100				30		31				65.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H0609	062	0	1	02	01	H0609_062_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				69.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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				371.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	063	0	1	02	01	H0609_063_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	063	0	1	02	01	H0609_063_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	063	0	1	02	01	H0609_063_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H0609	063	0	1	02	01	H0609_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	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	25						25			25			25		25
H0609	063	0	1	02	01	H0609_063_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H0609	065	0	1	02	01	H0609_065_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0609	065	0	1	02	01	H0609_065_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	065	0	1	02	01	H0609_065_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	24		24						24				24		24
H0609	065	0	1	02	01	H0609_065_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H0609	065	0	1	02	01	H0609_065_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				432.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	066	0	1	02	01	H0609_066_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	066	0	1	02	01	H0609_066_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	066	0	1	02	01	H0609_066_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0609	066	0	1	02	01	H0609_066_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	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	25						25			25			25		25
H0609	066	0	1	02	01	H0609_066_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H0609	067	0	1	02	01	H0609_067_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	067	0	1	02	01	H0609_067_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	067	0	1	02	01	H0609_067_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0609	067	0	1	02	01	H0609_067_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	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	25						25			25			25		25
H0609	067	0	1	02	01	H0609_067_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				392.00	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	25						25			25			25		25
H0609	068	0	1	02	01	H0609_068_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	068	0	1	02	01	H0609_068_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	068	0	1	02	01	H0609_068_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	068	0	1	02	01	H0609_068_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	068	0	1	02	01	H0609_068_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				336.00	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	25						25			25			25		25
H0609	070	0	1	02	01	H0609_070_0	3			Preferred Generic	4	01	1	2	1	1	110		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																														
H0609	070	0	1	02	01	H0609_070_0	3			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																														
H0609	070	0	1	02	01	H0609_070_0	3			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				44.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H0609	070	0	1	02	01	H0609_070_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				74.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	070	0	1	02	01	H0609_070_0	3			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	071	0	1	02	01	H0609_071_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	071	0	1	02	01	H0609_071_0	4			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																														
H0609	071	0	1	02	01	H0609_071_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				33.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	15		15						15				15		15
H0609	071	0	1	02	01	H0609_071_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				75.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	071	0	1	02	01	H0609_071_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				394.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	072	0	1	02	01	H0609_072_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	072	0	1	02	01	H0609_072_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	072	0	1	02	01	H0609_072_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				56.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H0609	072	0	1	02	01	H0609_072_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	072	0	1	02	01	H0609_072_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	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	25						25			25			25		25
H0609	073	0	1	02	01	H0609_073_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	073	0	1	02	01	H0609_073_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	073	0	1	02	01	H0609_073_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	073	0	1	02	01	H0609_073_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	073	0	1	02	01	H0609_073_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H0609	075	0	1	02	01	H0609_075_0	4			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	4			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	075	0	1	02	01	H0609_075_0	4			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		100	2	2						100	30		31											47.00	20		20				51.00	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H0609	075	0	1	02	01	H0609_075_0	4			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											72.00	29						91.00	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0609	075	0	1	02	01	H0609_075_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											462.00	29						444.00	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0609	076	0	1	02	01	H0609_076_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	076	0	1	02	01	H0609_076_0	4			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	076	0	1	02	01	H0609_076_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H0609	076	0	1	02	01	H0609_076_0	4			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	35.00						35.00						35.00		35.00	25						25						25		25
H0609	076	0	1	02	01	H0609_076_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				373.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0609	077	0	1	02	01	H0609_077_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	077	0	1	02	01	H0609_077_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	077	0	1	02	01	H0609_077_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0609	077	0	1	02	01	H0609_077_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	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	25						25			25			25		25
H0609	077	0	1	02	01	H0609_077_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	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	25						25			25			25		25
H0609	078	0	1	02	01	H0609_078_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	078	0	1	02	01	H0609_078_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	078	0	1	02	01	H0609_078_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0609	078	0	1	02	01	H0609_078_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	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	25						25			25			25		25
H0609	078	0	1	02	01	H0609_078_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
H0609	079	0	1	02	01	H0609_079_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	079	0	1	02	01	H0609_079_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	079	0	1	02	01	H0609_079_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0609	079	0	1	02	01	H0609_079_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				100.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	079	0	1	02	01	H0609_079_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				397.00	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	25						25			25			25		25
H0609	080	0	1	02	01	H0609_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																														
H0609	080	0	1	02	01	H0609_080_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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0609	080	0	1	02	01	H0609_080_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0609	080	0	1	02	01	H0609_080_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0609	080	0	1	02	01	H0609_080_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H0624	001	0	1	02	01	H0624_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0624	001	0	1	02	01	H0624_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0624	001	0	1	02	01	H0624_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H0624	001	0	1	02	01	H0624_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				52.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0624	001	0	1	02	01	H0624_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0624	006	0	1	02	01	H0624_006_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0624	006	0	1	02	01	H0624_006_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0624	006	0	1	02	01	H0624_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H0624	006	0	1	02	01	H0624_006_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0624	006	0	1	02	01	H0624_006_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				349.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	001	0	1	02	01	H0628_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																														
H0628	001	0	1	02	01	H0628_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																														
H0628	001	0	1	02	01	H0628_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											64.12	22	22	22				86.57	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	001	0	1	02	01	H0628_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											36.45	25	25	25				39.37	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	001	0	1	02	01	H0628_001_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											537.59	27						592.92	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	25			25			25			25			25		25
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											69.00	24	24	24				96.06	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.08	25	25	25				41.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											473.89	25						587.70	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											69.66	22	22	22				90.61	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											43.58	25	25	25				41.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											558.89	27						643.65	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											58.40	22	22	22				82.18	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											37.47	25	25	25				42.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											533.65	27						610.70	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											65.90	22	22	22				83.52	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											37.92	25	25	25				43.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											582.98	27						694.82	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0628	010	0	1	02	01	H0628_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																														
H0628	010	0	1	02	01	H0628_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																														
H0628	010	0	1	02	01	H0628_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											60.33	22	22	22				82.41	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	010	0	1	02	01	H0628_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											38.25	25	25	25				45.11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	010	0	1	02	01	H0628_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											551.22	27						655.09	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	25			25			25			25			25		25
H0628	012	0	1	01	01	H0628_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	012	0	1	01	01	H0628_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	012	0	1	01	01	H0628_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				68.11	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	22	22	22				22	22	22				22		22
H0628	012	0	1	01	01	H0628_012_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.07	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	012	0	1	01	01	H0628_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				451.40	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	013	0	1	01	01	H0628_013_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	013	0	1	01	01	H0628_013_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	013	0	1	01	01	H0628_013_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.25	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	22	22	22				22	22	22				22		22
H0628	013	0	1	01	01	H0628_013_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.94	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	013	0	1	01	01	H0628_013_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				468.05	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	017	0	1	02	01	H0628_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																														
H0628	017	0	1	02	01	H0628_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																														
H0628	017	0	1	02	01	H0628_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											63.68	22	22	22				86.81	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	017	0	1	02	01	H0628_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											37.17	25	25	25				38.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	017	0	1	02	01	H0628_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.31	27						608.28	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	25			25			25			25			25		25
H0628	019	0	1	02	01	H0628_019_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.89	24	24	24				95.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0628	019	0	1	02	01	H0628_019_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.35	25	25	25				50.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	019	0	1	02	01	H0628_019_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											575.74	25						705.17	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											65.47	24	24	24				94.52	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.28	25	25	25				47.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											563.14	25						721.87	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											62.96	24	24	24				86.91	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.74	25	25	25				44.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											525.93	25						692.82	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	25			25			25			25			25		25
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											64.31	24	24	24				90.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.11	25	25	25				46.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											535.11	25						672.44	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	25			25			25			25			25		25
H0628	031	0	1	01	01	H0628_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	031	0	1	01	01	H0628_031_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H0628	031	0	1	01	01	H0628_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				93.92	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	031	0	1	01	01	H0628_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				40.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	031	0	1	01	01	H0628_031_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.97	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	032	0	1	01	01	H0628_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	032	0	1	01	01	H0628_032_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H0628	032	0	1	01	01	H0628_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				93.92	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	032	0	1	01	01	H0628_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				40.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	032	0	1	01	01	H0628_032_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.97	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	033	0	1	01	01	H0628_033_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	033	0	1	01	01	H0628_033_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H0628	033	0	1	01	01	H0628_033_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				93.92	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	033	0	1	01	01	H0628_033_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				40.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	033	0	1	01	01	H0628_033_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.97	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	034	0	1	01	01	H0628_034_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	034	0	1	01	01	H0628_034_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H0628	034	0	1	01	01	H0628_034_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				93.92	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	034	0	1	01	01	H0628_034_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				40.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	034	0	1	01	01	H0628_034_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.97	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	035	0	1	01	01	H0628_035_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	035	0	1	01	01	H0628_035_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H0628	035	0	1	01	01	H0628_035_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				93.92	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	035	0	1	01	01	H0628_035_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				40.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	035	0	1	01	01	H0628_035_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.97	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	036	0	1	01	01	H0628_036_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	036	0	1	01	01	H0628_036_0	2			Generic	4	01	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	036	0	1	01	01	H0628_036_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.53	22	22	22				91.55	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	036	0	1	01	01	H0628_036_0	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				48.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	036	0	1	01	01	H0628_036_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.51	25						789.65	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	25			25			25			25			25		25
H0628	037	0	1	01	01	H0628_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																														
H0628	037	0	1	01	01	H0628_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																														
H0628	037	0	1	01	01	H0628_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											71.53	22	22	22				91.55	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	037	0	1	01	01	H0628_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											39.96	25	25	25				48.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	037	0	1	01	01	H0628_037_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.51	25						789.65	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	25			25			25			25			25		25
H0628	038	0	1	01	01	H0628_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																														
H0628	038	0	1	01	01	H0628_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					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	038	0	1	01	01	H0628_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											71.53	22	22	22				91.55	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	038	0	1	01	01	H0628_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											39.96	25	25	25				48.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	038	0	1	01	01	H0628_038_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.51	25						789.65	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	25			25			25			25			25		25
H0628	039	0	1	01	01	H0628_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																														
H0628	039	0	1	01	01	H0628_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					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	039	0	1	01	01	H0628_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											71.53	22	22	22				91.55	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H0628	039	0	1	01	01	H0628_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											39.96	25	25	25				48.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0628	039	0	1	01	01	H0628_039_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.51	25						789.65	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	25			25			25			25			25		25
H0628	040	0	1	01	01	H0628_040_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	040	0	1	01	01	H0628_040_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	040	0	1	01	01	H0628_040_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.46	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	22	22	22				22	22	22				22		22
H0628	040	0	1	01	01	H0628_040_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				33.98	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	040	0	1	01	01	H0628_040_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				456.89	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0628	041	0	1	01	01	H0628_041_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	041	0	1	01	01	H0628_041_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0628	041	0	1	01	01	H0628_041_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				74.42	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	22	22	22				22	22	22				22		22
H0628	041	0	1	01	01	H0628_041_0	2		N	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	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0628	041	0	1	01	01	H0628_041_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				458.94	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0629	001	0	1	01	01	H0629_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		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																														
H0629	001	0	1	01	01	H0629_001_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0629	001	0	1	01	01	H0629_001_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	001	0	1	01	01	H0629_001_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	001	0	1	01	01	H0629_001_0	5		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																														
H0629	001	0	1	01	01	H0629_001_0	5		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																														
H0629	002	0	1	01	01	H0629_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		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																														
H0629	002	0	1	01	01	H0629_002_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0629	002	0	1	01	01	H0629_002_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				73.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	002	0	1	01	01	H0629_002_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		34				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	002	0	1	01	01	H0629_002_0	5		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																														
H0629	002	0	1	01	01	H0629_002_0	5		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																														
H0629	003	0	1	01	01	H0629_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		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																														
H0629	003	0	1	01	01	H0629_003_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0629	003	0	1	01	01	H0629_003_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				75.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	003	0	1	01	01	H0629_003_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		34				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	003	0	1	01	01	H0629_003_0	5		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																														
H0629	003	0	1	01	01	H0629_003_0	5		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																														
H0629	004	0	1	01	01	H0629_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		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																														
H0629	004	0	1	01	01	H0629_004_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0629	004	0	1	01	01	H0629_004_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	004	0	1	01	01	H0629_004_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0629	004	0	1	01	01	H0629_004_0	5		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																														
H0629	004	0	1	01	01	H0629_004_0	5		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																														
H0630	013	0	1	01	01	H0630_013_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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	013	0	1	01	01	H0630_013_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					3.00	6.00	9.00					0.00	0.00	0.00																20.00				3.00			0.67	0.10	0.00			0.10	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	25	25	25	25	25	25	0	0	0				25		25
H0630	013	0	1	01	01	H0630_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					45.00	90.00	135.00					45.00	90.00	90.00																47.00				45.00			1.57	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	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H0630	013	0	1	01	01	H0630_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	013	0	1	01	01	H0630_013_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	013	0	1	01	01	H0630_013_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																														
H0630	014	0	1	01	01	H0630_014_0	5		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	0	0	0				0	0	0				0		0
H0630	014	0	1	01	01	H0630_014_0	5		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	0	0	0				0	0	0				0		0
H0630	014	0	1	01	01	H0630_014_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				43.00	15	15	15																		15	15	15															15			15								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	0	0	0				0	0	0				0		0
H0630	014	0	1	01	01	H0630_014_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				71.00	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	0	0	0				0	0	0				0		0
H0630	014	0	1	01	01	H0630_014_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				427.00	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	0	0	0				0	0	0				0		0
H0630	014	0	1	01	01	H0630_014_0	5		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	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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	015	0	1	02	01	H0630_015_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					0.00	0.00	0.00					0.00	0.00	0.00																20.00				0.00			0.67	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00				20.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H0630	015	0	1	02	01	H0630_015_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	015	0	1	02	01	H0630_015_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		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	25	25	25	25	25	25	25	25	25				25		25
H0630	015	0	1	02	01	H0630_015_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	015	0	1	02	01	H0630_015_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																														
H0630	016	0	1	02	01	H0630_016_0	6			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	25	25	25	0	0	0	0	0	0				25		0
H0630	016	0	1	02	01	H0630_016_0	6			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			0.67	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	25	25	25	0	0	0	0	0	0				25		0
H0630	016	0	1	02	01	H0630_016_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	016	0	1	02	01	H0630_016_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	016	0	1	02	01	H0630_016_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	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	25	25	25	25	25	25	25	25	25				25		25
H0630	016	0	1	02	01	H0630_016_0	6			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	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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	017	0	1	01	01	H0630_017_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H0630	017	0	1	01	01	H0630_017_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	017	0	1	01	01	H0630_017_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	017	0	1	01	01	H0630_017_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	017	0	1	01	01	H0630_017_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																														
H0630	020	0	1	01	01	H0630_020_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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	020	0	1	01	01	H0630_020_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H0630	020	0	1	01	01	H0630_020_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	020	0	1	01	01	H0630_020_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	020	0	1	01	01	H0630_020_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	020	0	1	01	01	H0630_020_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																														
H0630	021	0	1	02	01	H0630_021_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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	021	0	1	02	01	H0630_021_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					3.00	6.00	9.00					0.00	0.00	0.00																20.00				3.00			0.67	0.10	0.00			0.10	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	25	25	25	25	25	25	0	0	0				25		25
H0630	021	0	1	02	01	H0630_021_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	021	0	1	02	01	H0630_021_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	021	0	1	02	01	H0630_021_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	021	0	1	02	01	H0630_021_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																														
H0630	023	0	1	02	01	H0630_023_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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	023	0	1	02	01	H0630_023_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					5.00	10.00	15.00					0.00	0.00	0.00																20.00				5.00			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H0630	023	0	1	02	01	H0630_023_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	023	0	1	02	01	H0630_023_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	023	0	1	02	01	H0630_023_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	023	0	1	02	01	H0630_023_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																														
H0630	024	0	1	01	01	H0630_024_0	5		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	0	0	0				0	0	0				0		0
H0630	024	0	1	01	01	H0630_024_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				5.00	16	16	16																		16	16	16															16			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	0	0	0				0	0	0				0		0
H0630	024	0	1	01	01	H0630_024_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				71.00	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	0	0	0				0	0	0				0		0
H0630	024	0	1	01	01	H0630_024_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				70.00	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	0	0	0				0	0	0				0		0
H0630	024	0	1	01	01	H0630_024_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				378.00	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	0	0	0				0	0	0				0		0
H0630	024	0	1	01	01	H0630_024_0	5		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	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				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	25	25	25	0	0	0	0	0	0				25		0
H0630	025	0	1	02	01	H0630_025_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					0.00	0.00	0.00																20.00				7.00			0.67	0.23	0.00			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	7.00	14.00	21.00	0.00	0.00	0.00				20.00		7.00	25	25	25	25	25	25	0	0	0				25		25
H0630	025	0	1	02	01	H0630_025_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					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H0630	025	0	1	02	01	H0630_025_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					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	25	25	25	25	25	25	25	25	25				25		25
H0630	025	0	1	02	01	H0630_025_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												33	33	33					33	33	33				33	33	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	25	25	25	25	25	25	25	25	25				25		25
H0630	025	0	1	02	01	H0630_025_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																														
H0630	027	0	1	01	01	H0630_027_0	5		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	0	0	0				0	0	0				0		0
H0630	027	0	1	01	01	H0630_027_0	5		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	0	0	0				0	0	0				0		0
H0630	027	0	1	01	01	H0630_027_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				5.00	2	2	2																		2	2	2															2			2								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	0	0	0				0	0	0				0		0
H0630	027	0	1	01	01	H0630_027_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				66.00	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	0	0	0				0	0	0				0		0
H0630	027	0	1	01	01	H0630_027_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				391.00	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	0	0	0				0	0	0				0		0
H0630	027	0	1	01	01	H0630_027_0	5		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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0672	005	0	1	01	01	H0672_005_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	005	0	1	01	01	H0672_005_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											55.54	50	50	50				58.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											608.24	30						547.61	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H0672	006	0	1	01	01	H0672_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	006	0	1	01	01	H0672_006_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	006	0	1	01	01	H0672_006_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	006	0	1	01	01	H0672_006_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											76.09	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	006	0	1	01	01	H0672_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											728.93	28						605.32	28												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	25			25			25			25			25		25
H0672	009	0	1	01	01	H0672_009_0	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	009	0	1	01	01	H0672_009_0	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	009	0	1	01	01	H0672_009_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.30	25	25	25				30.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	009	0	1	01	01	H0672_009_0	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											55.11	25	25	25				57.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	009	0	1	01	01	H0672_009_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											524.16	25						421.83	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	25			25			25			25			25		25
H0672	010	0	1	01	01	H0672_010_0	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	010	0	1	01	01	H0672_010_0	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	010	0	1	01	01	H0672_010_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											26.45	24	24	24				30.95	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0672	010	0	1	01	01	H0672_010_0	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											55.22	25	25	25				59.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	010	0	1	01	01	H0672_010_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											549.02	25						459.95	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	013	0	1	01	01	H0672_013_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	013	0	1	01	01	H0672_013_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											71.58	50	50	50				62.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											719.32	30						561.42	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	25			25			25			25			25		25
H0672	015	0	1	01	01	H0672_015_0	4		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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	015	0	1	01	01	H0672_015_0	4		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0672	015	0	1	01	01	H0672_015_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.92	24	24	24				25.67	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H0672	015	0	1	01	01	H0672_015_0	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											53.09	25	25	25				56.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	015	0	1	01	01	H0672_015_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											525.10	25						529.60	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	016	0	1	01	01	H0672_016_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	016	0	1	01	01	H0672_016_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											72.53	50	50	50				66.62	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											616.27	30						730.89	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	017	0	1	01	01	H0672_017_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	017	0	1	01	01	H0672_017_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											50.70	50	50	50				44.68	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											796.51	33						569.83	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	25			25			25			25			25		25
H0672	018	0	1	01	01	H0672_018_0	4		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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	018	0	1	01	01	H0672_018_0	4		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0672	018	0	1	01	01	H0672_018_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											20.47	23	23	23				21.17	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H0672	018	0	1	01	01	H0672_018_0	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											50.73	25	25	25				55.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	018	0	1	01	01	H0672_018_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											459.48	25						454.37	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	25			25			25			25			25		25
H0672	024	0	1	01	01	H0672_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	9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H0672	024	0	1	01	01	H0672_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	15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H0672	024	0	1	01	01	H0672_024_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	024	0	1	01	01	H0672_024_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											72.26	50	50	50				69.93	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0672	024	0	1	01	01	H0672_024_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											574.02	30						579.06	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	25			25			25			25			25		25
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	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	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						0.39	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	25		25																										25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	25		25						25			25	25		25
H0710	030	0	1	04	01	H0710_030_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	45																										45						45					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				441.00	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	25						25			25			25		25
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	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	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						0.39	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	25		25																										25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	25		25						25			25	25		25
H0710	037	0	1	04	01	H0710_037_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				93.00	50																										50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				458.00	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	25						25			25			25		25
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	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	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						0.39	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	25		25																										25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	25		25						25			25	25		25
H0710	057	0	1	04	01	H0710_057_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	46																										46						46					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				387.00	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	25						25			25			25		25
H0712	005	0	1	02	01	H0712_005_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	005	0	1	02	01	H0712_005_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	005	0	1	02	01	H0712_005_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.89	20	20	20				77.89	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0712	005	0	1	02	01	H0712_005_0	9		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											48.31	32	32	32				48.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	005	0	1	02	01	H0712_005_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	005	0	1	02	01	H0712_005_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	019	0	1	02	01	H0712_019_0	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0712	019	0	1	02	01	H0712_019_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0712	019	0	1	02	01	H0712_019_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.07	25	25	25				112.07	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	019	0	1	02	01	H0712_019_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											94.64	37	37	37				89.53	35	35	35											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	019	0	1	02	01	H0712_019_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	019	0	1	02	01	H0712_019_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	029	0	1	01	01	H0712_029_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	029	0	1	01	01	H0712_029_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	029	0	1	01	01	H0712_029_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.90	20	20	20				79.90	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0712	029	0	1	01	01	H0712_029_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											45.45	32	32	32				45.45	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	029	0	1	01	01	H0712_029_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	029	0	1	01	01	H0712_029_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0712	032	0	1	02	01	H0712_032_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0712	032	0	1	02	01	H0712_032_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											124.34	25	25	25				124.34	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	032	0	1	02	01	H0712_032_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											61.83	34	34	34				61.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0712	032	0	1	02	01	H0712_032_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0712	032	0	1	02	01	H0712_032_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	001	0	1	01	01	H0738_001_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				5.80	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	001	0	1	01	01	H0738_001_0	6		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				17.93	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	001	0	1	01	01	H0738_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				105.85	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	001	0	1	01	01	H0738_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				25.63	26	26	26																			26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	001	0	1	01	01	H0738_001_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				559.63	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	001	0	1	01	01	H0738_001_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	002	0	1	01	01	H0738_002_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				4.88	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	002	0	1	01	01	H0738_002_0	6		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				13.65	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	002	0	1	01	01	H0738_002_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				110.43	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	002	0	1	01	01	H0738_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				25.97	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H0738	002	0	1	01	01	H0738_002_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				618.81	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0738	002	0	1	01	01	H0738_002_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0755	030	0	1	02	01	H0755_030_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	030	0	1	02	01	H0755_030_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	030	0	1	02	01	H0755_030_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0755	030	0	1	02	01	H0755_030_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0755	030	0	1	02	01	H0755_030_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				476.00	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	25						25			25			25		25
H0755	031	0	1	02	01	H0755_031_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	031	0	1	02	01	H0755_031_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	031	0	1	02	01	H0755_031_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H0755	031	0	1	02	01	H0755_031_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0755	031	0	1	02	01	H0755_031_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				408.00	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	25						25			25			25		25
H0755	033	0	1	02	01	H0755_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	033	0	1	02	01	H0755_033_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	033	0	1	02	01	H0755_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0755	033	0	1	02	01	H0755_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				93.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0755	033	0	1	02	01	H0755_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				413.00	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	25						25			25			25		25
H0755	038	0	1	02	01	H0755_038_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	038	0	1	02	01	H0755_038_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	038	0	1	02	01	H0755_038_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H0755	038	0	1	02	01	H0755_038_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	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	25						25			25			25		25
H0755	038	0	1	02	01	H0755_038_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H0755	044	0	1	02	01	H0755_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	044	0	1	02	01	H0755_044_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	044	0	1	02	01	H0755_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0755	044	0	1	02	01	H0755_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0755	044	0	1	02	01	H0755_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H0755	045	0	1	02	01	H0755_045_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	045	0	1	02	01	H0755_045_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	045	0	1	02	01	H0755_045_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H0755	045	0	1	02	01	H0755_045_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				92.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H0755	045	0	1	02	01	H0755_045_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				438.00	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	25						25			25			25		25
H0755	046	0	1	02	01	H0755_046_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	046	0	1	02	01	H0755_046_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0755	046	0	1	02	01	H0755_046_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H0755	046	0	1	02	01	H0755_046_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	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	25						25			25			25		25
H0755	046	0	1	02	01	H0755_046_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				374.00	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	25						25			25			25		25
H0764	001	0	1	04	01	H0764_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H0764	001	0	1	04	01	H0764_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0764	001	0	1	04	01	H0764_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H0764	001	0	1	04	01	H0764_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0764	001	0	1	04	01	H0764_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				355.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H0783	004	0	1	01	01	H0783_004_0	2			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	0		0				25		25	0		0	0		0
H0783	004	0	1	01	01	H0783_004_0	2			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	25		25				25		25	25		0	25		25
H0783	004	0	1	01	01	H0783_004_0	2			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	25		25				25		25	25		25	25		25
H0783	004	0	1	01	01	H0783_004_0	2			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	25		25				25		25	25		25	25		25
H0783	004	0	1	01	01	H0783_004_0	2			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	25						25			25			25		25
H0816	001	0	1	02	01	H0816_001_0	8			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																														
H0816	001	0	1	02	01	H0816_001_0	8			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	14.00	28.00	42.00																			14.00	28.00	42.00																14.00				14.00		0.41			0.41			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0816	001	0	1	02	01	H0816_001_0	8			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	25	25	25				25	25	25				25		25
H0816	001	0	1	02	01	H0816_001_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34				94.97	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0816	001	0	1	02	01	H0816_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				931.13	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0816	001	0	1	02	01	H0816_001_0	8			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																														
H0816	002	0	1	02	01	H0816_002_0	8			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																														
H0816	002	0	1	02	01	H0816_002_0	8			Generic	4	11	1	2	2	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34	14.00	28.00	42.00																			14.00	28.00	42.00																14.00				14.00		0.41			0.41			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0816	002	0	1	02	01	H0816_002_0	8			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	25	25	25				25	25	25				25		25
H0816	002	0	1	02	01	H0816_002_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34				99.29	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0816	002	0	1	02	01	H0816_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				848.52	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0816	002	0	1	02	01	H0816_002_0	8			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																														
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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	001	0	1	04	01	H0885_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				96.02	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				591.76	29																																					29			29								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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	002	0	1	04	01	H0885_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				79.69	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				527.73	29																																					29			29								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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	003	0	1	04	01	H0885_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				92.95	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				547.90	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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	005	0	1	04	01	H0885_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				82.13	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				581.55	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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	006	0	1	04	01	H0885_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				85.03	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				539.37	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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	007	0	1	04	01	H0885_007_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				91.70	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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				603.59	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	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	0	0	0				0	0	0	0	0	0	0		0
H0885	008	0	1	04	01	H0885_008_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	25	25	25				25	25	25	25	25	25	25		25
H0885	008	0	1	04	01	H0885_008_0	5			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	94.00	141.00				47.00				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	25	25	25				25	25	25	25	25	25	25		25
H0885	008	0	1	04	01	H0885_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				84.13	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		35.00	25	25	25				25	25	25	25	25	25	25		25
H0885	008	0	1	04	01	H0885_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				505.06	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	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	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	0	0	0				0	0	0	0	0	0	0		0
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	25	25	25				25	25	25	25	25	25	25		25
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	25	25	25				25	25	25	25	25	25	25		25
H0885	009	0	1	04	01	H0885_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				77.60	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	25	25	25				25	25	25	25	25	25	25		25
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				530.91	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																														
H0907	001	0	1	02	01	H0907_001_0	4		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																														
H0907	001	0	1	02	01	H0907_001_0	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0907	001	0	1	02	01	H0907_001_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0907	001	0	1	02	01	H0907_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0907	001	0	1	02	01	H0907_001_0	4		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																														
H0907	001	0	1	02	01	H0907_001_0	4		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																														
H0907	003	0	1	02	01	H0907_003_0	4		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																														
H0907	003	0	1	02	01	H0907_003_0	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0907	003	0	1	02	01	H0907_003_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0907	003	0	1	02	01	H0907_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H0907	003	0	1	02	01	H0907_003_0	4		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																														
H0907	003	0	1	02	01	H0907_003_0	4		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																														
H0908	001	0	1	02	01	H0908_001_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	001	0	1	02	01	H0908_001_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.47	21	21	21				87.12	20	20	20											21	21					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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	20	20	20		21	21		20	20	21		21
H0908	001	0	1	02	01	H0908_001_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	001	0	1	02	01	H0908_001_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0908	003	0	1	02	01	H0908_003_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0908	003	0	1	02	01	H0908_003_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.94	25	25	25				123.94	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	003	0	1	02	01	H0908_003_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											76.37	41	41	41				76.37	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	003	0	1	02	01	H0908_003_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	003	0	1	02	01	H0908_003_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	004	0	1	02	01	H0908_004_0	10			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	10			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.46	22	22	22				93.46	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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	22	22	22		22	22		22	22	22		22
H0908	004	0	1	02	01	H0908_004_0	10			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	004	0	1	02	01	H0908_004_0	10			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	10			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	006	0	1	02	01	H0908_006_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											102.35	24	24	24				98.09	23	23	23											24	24					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		70.00	105.00		70.00	105.00	35.00		35.00	24	24	24	23	23	23		24	24		23	23	24		24
H0908	006	0	1	02	01	H0908_006_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	006	0	1	02	01	H0908_006_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	007	0	1	02	01	H0908_007_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	007	0	1	02	01	H0908_007_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	007	0	1	02	01	H0908_007_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.26	20	20	20				83.26	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0908	007	0	1	02	01	H0908_007_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											43.55	32	32	32				43.55	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	007	0	1	02	01	H0908_007_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	007	0	1	02	01	H0908_007_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	008	0	1	02	01	H0908_008_0	14		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	008	0	1	02	01	H0908_008_0	14		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	008	0	1	02	01	H0908_008_0	14		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.08	25	25	25				99.08	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	008	0	1	02	01	H0908_008_0	14		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0908	008	0	1	02	01	H0908_008_0	14		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0908	008	0	1	02	01	H0908_008_0	14		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	002	0	1	02	01	H0913_002_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0913	002	0	1	02	01	H0913_002_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0913	002	0	1	02	01	H0913_002_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											114.67	25	25	25				114.67	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	002	0	1	02	01	H0913_002_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.25	36	36	36				96.49	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	002	0	1	02	01	H0913_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	002	0	1	02	01	H0913_002_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	013	0	1	01	01	H0913_013_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	013	0	1	01	01	H0913_013_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.33	22	22	22				83.33	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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	22	22	22		22	22		22	22	22		22
H0913	013	0	1	01	01	H0913_013_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	013	0	1	01	01	H0913_013_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					10.00	20.00	30.00												38.00	57.00					20.00	0.00				19.00				19.00			0.63	0.33				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	015	0	1	02	01	H0913_015_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.84	20	20	20				78.84	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H0913	015	0	1	02	01	H0913_015_0	9			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	015	0	1	02	01	H0913_015_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0913	021	0	1	02	01	H0913_021_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0913	021	0	1	02	01	H0913_021_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											115.68	25	25	25				115.68	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	021	0	1	02	01	H0913_021_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.91	36	36	36				75.91	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	021	0	1	02	01	H0913_021_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	021	0	1	02	01	H0913_021_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	022	0	1	02	01	H0913_022_0	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H0913	022	0	1	02	01	H0913_022_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H0913	022	0	1	02	01	H0913_022_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											118.29	25	25	25				118.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	022	0	1	02	01	H0913_022_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											59.99	39	39	39				56.91	37	37	37											39	39					37	37			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H0913	022	0	1	02	01	H0913_022_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0913	022	0	1	02	01	H0913_022_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H0963	001	0	1	01	01	H0963_001_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	0		0				25		25	0		0	0		0
H0963	001	0	1	01	01	H0963_001_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	0		0				25		25	0		0	0		0
H0963	001	0	1	01	01	H0963_001_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0963	001	0	1	01	01	H0963_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H0963	001	0	1	01	01	H0963_001_0	5		N	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	25						25			25			25		25
H0976	001	0	1	01	01	H0976_001_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	0.00				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	10		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	10		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											104.72	25	25	25				104.72	25	25	25										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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H0976	001	0	1	01	01	H0976_001_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											57.79	29	29	29				57.79	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0976	001	0	1	01	01	H0976_001_0	10		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	9		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	9		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	9		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											94.36	25	25	25				94.36	25	25	25										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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H0976	002	0	1	01	01	H0976_002_0	9		N	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	29	29	29				54.74	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0976	002	0	1	01	01	H0976_002_0	9		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	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0978	001	0	1	01	01	H0978_001_0	6			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	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0978	001	0	1	01	01	H0978_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											36.76	35	35	35				36.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0978	001	0	1	01	01	H0978_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0978	002	0	1	01	01	H0978_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0978	002	0	1	01	01	H0978_002_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0978	002	0	1	01	01	H0978_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H0978	002	0	1	01	01	H0978_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											50.19	35	35	35				50.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0978	002	0	1	01	01	H0978_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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											102.35	25	25	25				102.35	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											59.83	30	30	30				59.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	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																														
H0978	011	0	1	01	01	H0978_011_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0978	011	0	1	01	01	H0978_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											33.12	35	35	35				33.12	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H0978	011	0	1	01	01	H0978_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H0982	002	0	1	01	01	H0982_002_0	13		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	002	0	1	01	01	H0982_002_0	13		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	002	0	1	01	01	H0982_002_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				57.36	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	25	25	25										25		25
H0982	002	0	1	01	01	H0982_002_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				62.06	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	002	0	1	01	01	H0982_002_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																														
H0982	002	0	1	01	01	H0982_002_0	13		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	12			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	007	0	1	01	01	H0982_007_0	12			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	007	0	1	01	01	H0982_007_0	12			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	15.00	30.00	40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	15.00	30.00	40.00										15.00		15.00	25	25	25										25		25
H0982	007	0	1	01	01	H0982_007_0	12			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	70.00																																							70.00				70.00		2.33						2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	007	0	1	01	01	H0982_007_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H0982	007	0	1	01	01	H0982_007_0	12			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	10			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	008	0	1	01	01	H0982_008_0	10			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	008	0	1	01	01	H0982_008_0	10			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	20.00	40.00	55.00																																					20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	20.00	40.00	55.00										20.00		20.00	25	25	25										25		25
H0982	008	0	1	01	01	H0982_008_0	10			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	008	0	1	01	01	H0982_008_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, Supplemental Drugs																														
H0982	008	0	1	01	01	H0982_008_0	10			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	10			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	009	0	1	01	01	H0982_009_0	10			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	009	0	1	01	01	H0982_009_0	10			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	25.00	50.00	70.00																																					25.00				25.00		0.83						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	25.00	50.00	70.00										25.00		25.00	25	25	25										25		25
H0982	009	0	1	01	01	H0982_009_0	10			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	009	0	1	01	01	H0982_009_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, Supplemental Drugs																														
H0982	009	0	1	01	01	H0982_009_0	10			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	10		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	010	0	1	01	01	H0982_010_0	10		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	010	0	1	01	01	H0982_010_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				51.09	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	25	25	25										25		25
H0982	010	0	1	01	01	H0982_010_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				55.91	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	010	0	1	01	01	H0982_010_0	10		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	10		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	10		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	012	0	1	01	01	H0982_012_0	10		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	012	0	1	01	01	H0982_012_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				62.36	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	25	25	25										25		25
H0982	012	0	1	01	01	H0982_012_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				68.18	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	012	0	1	01	01	H0982_012_0	10		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	10		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	10		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	013	0	1	01	01	H0982_013_0	10		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	013	0	1	01	01	H0982_013_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				55.14	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	25	25	25										25		25
H0982	013	0	1	01	01	H0982_013_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				58.31	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	013	0	1	01	01	H0982_013_0	10		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	10		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	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	016	0	1	01	01	H0982_016_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	016	0	1	01	01	H0982_016_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	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, Supplemental Drugs	0.00	0.00	0.00										0.00		0.00	0	0	0										0		0
H0982	016	0	1	01	01	H0982_016_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	25.00																																							25.00				25.00		0.83						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	25.00												25.00		25.00	25												25		25
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					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	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	017	0	1	01	01	H0982_017_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	017	0	1	01	01	H0982_017_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	15.00	30.00	40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	15.00	30.00	40.00										15.00		15.00	25	25	25										25		25
H0982	017	0	1	01	01	H0982_017_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	70.00																																							70.00				70.00		2.33						2.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	017	0	1	01	01	H0982_017_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, Supplemental Drugs																														
H0982	017	0	1	01	01	H0982_017_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	018	0	1	01	01	H0982_018_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	018	0	1	01	01	H0982_018_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	018	0	1	01	01	H0982_018_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	15.00	30.00	40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	15.00	30.00	40.00										15.00		15.00	25	25	25										25		25
H0982	018	0	1	01	01	H0982_018_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	018	0	1	01	01	H0982_018_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, Supplemental Drugs																														
H0982	018	0	1	01	01	H0982_018_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	019	0	1	01	01	H0982_019_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	019	0	1	01	01	H0982_019_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	019	0	1	01	01	H0982_019_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	25.00	50.00	70.00																																					25.00				25.00		0.83						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	25.00	50.00	70.00										25.00		25.00	25	25	25										25		25
H0982	019	0	1	01	01	H0982_019_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	019	0	1	01	01	H0982_019_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, Supplemental Drugs																														
H0982	019	0	1	01	01	H0982_019_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	020	0	1	01	01	H0982_020_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	020	0	1	01	01	H0982_020_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	020	0	1	01	01	H0982_020_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	15.00	30.00	40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	15.00	30.00	40.00										15.00		15.00	25	25	25										25		25
H0982	020	0	1	01	01	H0982_020_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	020	0	1	01	01	H0982_020_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, Supplemental Drugs																														
H0982	020	0	1	01	01	H0982_020_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	021	0	1	01	01	H0982_021_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	021	0	1	01	01	H0982_021_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	021	0	1	01	01	H0982_021_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	15.00	30.00	40.00																																					15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	15.00	30.00	40.00										15.00		15.00	25	25	25										25		25
H0982	021	0	1	01	01	H0982_021_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	021	0	1	01	01	H0982_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, Supplemental Drugs																														
H0982	021	0	1	01	01	H0982_021_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	022	0	1	01	01	H0982_022_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	022	0	1	01	01	H0982_022_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	022	0	1	01	01	H0982_022_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	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, Supplemental Drugs	0.00	0.00	0.00										0.00		0.00	0	0	0										0		0
H0982	022	0	1	01	01	H0982_022_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	35.00																																							35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	022	0	1	01	01	H0982_022_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, Supplemental Drugs																														
H0982	022	0	1	01	01	H0982_022_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	023	0	1	01	01	H0982_023_0	10		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	023	0	1	01	01	H0982_023_0	10		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	023	0	1	01	01	H0982_023_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				51.98	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	25	25	25										25		25
H0982	023	0	1	01	01	H0982_023_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				56.45	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	023	0	1	01	01	H0982_023_0	10		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	10		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	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	024	0	1	01	01	H0982_024_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	024	0	1	01	01	H0982_024_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	30.00	60.00	85.00																																					30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	30.00	60.00	85.00										30.00		30.00	25	25	25										25		25
H0982	024	0	1	01	01	H0982_024_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	80.00																																							80.00				80.00		2.67						2.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	024	0	1	01	01	H0982_024_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, Supplemental Drugs																														
H0982	024	0	1	01	01	H0982_024_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	025	0	1	01	01	H0982_025_0	10		N	Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	025	0	1	01	01	H0982_025_0	10		N	Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	025	0	1	01	01	H0982_025_0	10		N	Preferred Brand	4	11	1	1	3	1	111		01	000		1	30	60	90				2	2							30		31				51.88	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	25	25	25										25		25
H0982	025	0	1	01	01	H0982_025_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				56.38	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	025	0	1	01	01	H0982_025_0	10		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	10		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	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	026	0	1	01	01	H0982_026_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	026	0	1	01	01	H0982_026_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	25.00	50.00	70.00																																					25.00				25.00		0.83						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	25.00	50.00	70.00										25.00		25.00	25	25	25										25		25
H0982	026	0	1	01	01	H0982_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	026	0	1	01	01	H0982_026_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, Supplemental Drugs																														
H0982	026	0	1	01	01	H0982_026_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	027	0	1	01	01	H0982_027_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	027	0	1	01	01	H0982_027_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	027	0	1	01	01	H0982_027_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	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, Supplemental Drugs	0.00	0.00	0.00										0.00		0.00	0	0	0										0		0
H0982	027	0	1	01	01	H0982_027_0	9			Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				51.04	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	027	0	1	01	01	H0982_027_0	9			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	027	0	1	01	01	H0982_027_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	028	0	1	01	01	H0982_028_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	028	0	1	01	01	H0982_028_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	028	0	1	01	01	H0982_028_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	35.00	70.00	100.00																																					35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00	70.00	100.00										35.00		35.00	25	25	25										25		25
H0982	028	0	1	01	01	H0982_028_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	028	0	1	01	01	H0982_028_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, Supplemental Drugs																														
H0982	028	0	1	01	01	H0982_028_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	030	0	1	01	01	H0982_030_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	030	0	1	01	01	H0982_030_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	030	0	1	01	01	H0982_030_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	35.00	70.00	100.00																																					35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00	70.00	100.00										35.00		35.00	25	25	25										25		25
H0982	030	0	1	01	01	H0982_030_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	030	0	1	01	01	H0982_030_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, Supplemental Drugs																														
H0982	030	0	1	01	01	H0982_030_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	031	0	1	01	01	H0982_031_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	031	0	1	01	01	H0982_031_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	031	0	1	01	01	H0982_031_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	30.00	60.00	85.00																																					30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	30.00	60.00	85.00										30.00		30.00	25	25	25										25		25
H0982	031	0	1	01	01	H0982_031_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	031	0	1	01	01	H0982_031_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, Supplemental Drugs																														
H0982	031	0	1	01	01	H0982_031_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	032	0	1	01	01	H0982_032_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	032	0	1	01	01	H0982_032_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	032	0	1	01	01	H0982_032_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	30.00	60.00	85.00																																					30.00				30.00		1.00						0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	30.00	60.00	85.00										30.00		30.00	25	25	25										25		25
H0982	032	0	1	01	01	H0982_032_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	032	0	1	01	01	H0982_032_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, Supplemental Drugs																														
H0982	032	0	1	01	01	H0982_032_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	033	0	1	01	01	H0982_033_0	9			Preferred Generic	4	11	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	033	0	1	01	01	H0982_033_0	9			Generic	4	01	1	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 Drug, Specialty Tier, Supplemental Drugs																														
H0982	033	0	1	01	01	H0982_033_0	9			Preferred Brand	4	11	1	2	3	1	111		01	000		1	30	60	90				2	2							30		31	35.00	70.00	100.00																																					35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00	70.00	100.00										35.00		35.00	25	25	25										25		25
H0982	033	0	1	01	01	H0982_033_0	9			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H0982	033	0	1	01	01	H0982_033_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, Supplemental Drugs																														
H0982	033	0	1	01	01	H0982_033_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																														
H1019	001	0	1	02	01	H1019_001_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																									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	0		0				25		25	0		0	0		0
H1019	001	0	1	02	01	H1019_001_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	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1019	001	0	1	02	01	H1019_001_0	4			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	0		0				25		25	0		0	0		0
H1019	001	0	1	02	01	H1019_001_0	4			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	25		25				25		25	25		25	25		25
H1019	001	0	1	02	01	H1019_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	25						25			25			25		25
H1019	006	0	1	01	01	H1019_006_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	0		0				0		0	0		0	0		0
H1019	006	0	1	01	01	H1019_006_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	0		0				0		0	0		0	0		0
H1019	006	0	1	01	01	H1019_006_0	4			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	0		0				25		25	0		0	0		0
H1019	006	0	1	01	01	H1019_006_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	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	25		25				25		25	25		25	25		25
H1019	006	0	1	01	01	H1019_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	023	0	1	01	01	H1019_023_0	6		N	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	0		0				25		25	0		0	0		0
H1019	023	0	1	01	01	H1019_023_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	0		0				25		25	0		0	0		0
H1019	023	0	1	01	01	H1019_023_0	6		N	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	25		25				25		25	25		25	25		25
H1019	023	0	1	01	01	H1019_023_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	023	0	1	01	01	H1019_023_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	043	0	1	02	01	H1019_043_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	0		0				25		25	0		0	0		0
H1019	043	0	1	02	01	H1019_043_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	0		0				25		25	0		0	0		0
H1019	043	0	1	02	01	H1019_043_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	25		25				25		25	25		25	25		25
H1019	043	0	1	02	01	H1019_043_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	25		25				25		25	25		25	25		25
H1019	043	0	1	02	01	H1019_043_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	25						25			25			25		25
H1019	057	0	1	02	01	H1019_057_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1019	057	0	1	02	01	H1019_057_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	0		0				25		25	0		0	0		0
H1019	057	0	1	02	01	H1019_057_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	25		25				25		25	25		25	25		25
H1019	057	0	1	02	01	H1019_057_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	057	0	1	02	01	H1019_057_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
H1019	065	0	1	01	01	H1019_065_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1019	073	0	1	01	01	H1019_073_0	6		N	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	0		0				25		25	0		0	0		0
H1019	073	0	1	01	01	H1019_073_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	0		0				25		25	0		0	0		0
H1019	073	0	1	01	01	H1019_073_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	073	0	1	01	01	H1019_073_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	073	0	1	01	01	H1019_073_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				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		35.00	25		25				25		25	25		25	25		25
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					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	103	1	1	01	01	H1019_103_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	0		0				25		25	0		0	0		0
H1019	103	1	1	01	01	H1019_103_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	0		0				25		25	0		0	0		0
H1019	103	1	1	01	01	H1019_103_1	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	5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00	25		25				25		25	25		25	25		25
H1019	103	1	1	01	01	H1019_103_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H1019	103	1	1	01	01	H1019_103_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	25						25			25			25		25
H1019	103	2	1	01	01	H1019_103_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	0		0				25		25	0		0	0		0
H1019	103	2	1	01	01	H1019_103_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	0		0				25		25	0		0	0		0
H1019	103	2	1	01	01	H1019_103_2	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	5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00	25		25				25		25	25		25	25		25
H1019	103	2	1	01	01	H1019_103_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H1019	103	2	1	01	01	H1019_103_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	25						25			25			25		25
H1019	104	1	1	01	01	H1019_104_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	0		0				25		25	0		0	0		0
H1019	104	1	1	01	01	H1019_104_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	0		0				25		25	0		0	0		0
H1019	104	1	1	01	01	H1019_104_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	25		25				25		25	25		25	25		25
H1019	104	1	1	01	01	H1019_104_1	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1019	104	1	1	01	01	H1019_104_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	25						25			25			25		25
H1019	104	2	1	01	01	H1019_104_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	0		0				25		25	0		0	0		0
H1019	104	2	1	01	01	H1019_104_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	0		0				25		25	0		0	0		0
H1019	104	2	1	01	01	H1019_104_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	25		25				25		25	25		25	25		25
H1019	104	2	1	01	01	H1019_104_2	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1019	104	2	1	01	01	H1019_104_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	25						25			25			25		25
H1019	109	0	1	01	01	H1019_109_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	0		0				25		25	0		0	0		0
H1019	109	0	1	01	01	H1019_109_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	25		25				25		25	25		0	25		25
H1019	109	0	1	01	01	H1019_109_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	109	0	1	01	01	H1019_109_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	109	0	1	01	01	H1019_109_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	25						25			25			25		25
H1019	109	0	1	01	01	H1019_109_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	0		0				0		0	0		0	0		0
H1019	113	0	1	01	01	H1019_113_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	0		0				25		25	0		0	0		0
H1019	113	0	1	01	01	H1019_113_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	0		0				25		25	0		0	0		0
H1019	113	0	1	01	01	H1019_113_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	25		25				25		25	25		25	25		25
H1019	113	0	1	01	01	H1019_113_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	25		25				25		25	25		25	25		25
H1019	113	0	1	01	01	H1019_113_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	25						25			25			25		25
H1019	118	0	1	01	01	H1019_118_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	0		0				25		25	0		0	0		0
H1019	118	0	1	01	01	H1019_118_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	25		25				25		25	25		0	25		25
H1019	118	0	1	01	01	H1019_118_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	118	0	1	01	01	H1019_118_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	118	0	1	01	01	H1019_118_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	25						25			25			25		25
H1019	118	0	1	01	01	H1019_118_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	0		0				0		0	0		0	0		0
H1019	121	0	1	01	01	H1019_121_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																									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	0		0				25		25	0		0	0		0
H1019	121	0	1	01	01	H1019_121_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																									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	25		25				25		25	25		0	25		25
H1019	121	0	1	01	01	H1019_121_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																									26.00		78.00				25.00		50.00				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		50.00	25.00		25.00	25		25				25		25	25		25	25		25
H1019	121	0	1	01	01	H1019_121_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				49.00	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	25		25				25		25	25		25	25		25
H1019	121	0	1	01	01	H1019_121_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	25						25			25			25		25
H1019	121	0	1	01	01	H1019_121_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	0		0				0		0	0		0	0		0
H1019	123	0	1	01	01	H1019_123_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																									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	0		0				25		25	0		0	0		0
H1019	123	0	1	01	01	H1019_123_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																									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	25		25				25		25	25		0	25		25
H1019	123	0	1	01	01	H1019_123_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																									26.00		78.00				25.00		50.00				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		50.00	25.00		25.00	25		25				25		25	25		25	25		25
H1019	123	0	1	01	01	H1019_123_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	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	25		25				25		25	25		25	25		25
H1019	123	0	1	01	01	H1019_123_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	25						25			25			25		25
H1019	123	0	1	01	01	H1019_123_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	0		0				0		0	0		0	0		0
H1019	124	0	1	02	01	H1019_124_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	0		0				0		0	0		0	0		0
H1019	124	0	1	02	01	H1019_124_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																									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	25		25				25		25	25		0	25		25
H1019	124	0	1	02	01	H1019_124_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	124	0	1	02	01	H1019_124_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	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	25		25				25		25	25		25	25		25
H1019	124	0	1	02	01	H1019_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	124	0	1	02	01	H1019_124_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	0		0				0		0	0		0	0		0
H1019	130	0	1	02	01	H1019_130_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	0		0				0		0	0		0	0		0
H1019	130	0	1	02	01	H1019_130_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																									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	25		25				25		25	25		0	25		25
H1019	130	0	1	02	01	H1019_130_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	130	0	1	02	01	H1019_130_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				49.00	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	25		25				25		25	25		25	25		25
H1019	130	0	1	02	01	H1019_130_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	25						25			25			25		25
H1019	130	0	1	02	01	H1019_130_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	0		0				0		0	0		0	0		0
H1019	134	0	1	01	01	H1019_134_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	0		0				25		25	0		0	0		0
H1019	134	0	1	01	01	H1019_134_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	0		0				25		25	0		0	0		0
H1019	134	0	1	01	01	H1019_134_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	25		25				25		25	25		25	25		25
H1019	134	0	1	01	01	H1019_134_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	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	25		25				25		25	25		25	25		25
H1019	134	0	1	01	01	H1019_134_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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	0		0				0		0	0		0	0		0
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	25		25				25		25	25		25	25		25
H1019	135	0	1	02	01	H1019_135_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1019	136	0	1	01	01	H1019_136_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	0		0				0		0	0		0	0		0
H1019	136	0	1	01	01	H1019_136_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	0		0				0		0	0		0	0		0
H1019	136	0	1	01	01	H1019_136_0	4			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	0		0				25		25	0		0	0		0
H1019	136	0	1	01	01	H1019_136_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																								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	25		25				25		25	25		25	25		25
H1019	136	0	1	01	01	H1019_136_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	25						25			25			25		25
H1019	138	0	1	01	01	H1019_138_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	0		0				0		0	0		0	0		0
H1019	138	0	1	01	01	H1019_138_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	0		0				0		0	0		0	0		0
H1019	138	0	1	01	01	H1019_138_0	4			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	25		25				25		25	25		25	25		25
H1019	138	0	1	01	01	H1019_138_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1019	138	0	1	01	01	H1019_138_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				47.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1019	144	0	1	01	01	H1019_144_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																									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	0		0				25		25	0		0	0		0
H1019	144	0	1	01	01	H1019_144_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																									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	0		0				25		25	0		0	0		0
H1019	144	0	1	01	01	H1019_144_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	25		25				25		25	25		25	25		25
H1019	144	0	1	01	01	H1019_144_0	6			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	25		25				25		25	25		25	25		25
H1019	144	0	1	01	01	H1019_144_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	25						25			25			25		25
H1019	146	0	1	01	01	H1019_146_0	6		N	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	0		0				25		25	0		0	0		0
H1019	146	0	1	01	01	H1019_146_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	0		0				25		25	0		0	0		0
H1019	146	0	1	01	01	H1019_146_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	146	0	1	01	01	H1019_146_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	146	0	1	01	01	H1019_146_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				72.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1019	147	2	1	01	01	H1019_147_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																									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	0		0				25		25	0		0	0		0
H1019	147	2	1	01	01	H1019_147_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																									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	0		0				25		25	0		0	0		0
H1019	147	2	1	01	01	H1019_147_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, Select Care Drugs	30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00	25		25				25		25	25		25	25		25
H1019	147	2	1	01	01	H1019_147_2	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	147	2	1	01	01	H1019_147_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	147	2	1	01	01	H1019_147_2	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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				73.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
H1019	149	0	1	01	01	H1019_149_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	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	150	0	1	01	01	H1019_150_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																									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	0		0				25		25	0		0	0		0
H1019	150	0	1	01	01	H1019_150_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																									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	0		0				25		25	0		0	0		0
H1019	150	0	1	01	01	H1019_150_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	40.00		120.00																									47.00		141.00				40.00		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	25		25				25		25	25		25	25		25
H1019	150	0	1	01	01	H1019_150_0	6			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	150	0	1	01	01	H1019_150_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	150	0	1	01	01	H1019_150_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	0		0				0		0	0		0	0		0
H1019	151	1	1	01	01	H1019_151_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	0		0				25		25	0		0	0		0
H1019	151	1	1	01	01	H1019_151_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																									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	25		25				25		25	25		0	25		25
H1019	151	1	1	01	01	H1019_151_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	151	1	1	01	01	H1019_151_1	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	151	1	1	01	01	H1019_151_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	151	1	1	01	01	H1019_151_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	0		0				0		0	0		0	0		0
H1019	151	2	1	01	01	H1019_151_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																									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	0		0				25		25	0		0	0		0
H1019	151	2	1	01	01	H1019_151_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																									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	25		25				25		25	25		0	25		25
H1019	151	2	1	01	01	H1019_151_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	151	2	1	01	01	H1019_151_2	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	151	2	1	01	01	H1019_151_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	151	2	1	01	01	H1019_151_2	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	0		0				0		0	0		0	0		0
H1019	152	0	1	01	01	H1019_152_0	4		N	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	0		0				25		25	0		0	0		0
H1019	152	0	1	01	01	H1019_152_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	0		0				25		25	0		0	0		0
H1019	152	0	1	01	01	H1019_152_0	4		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H1019	152	0	1	01	01	H1019_152_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	152	0	1	01	01	H1019_152_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	153	0	1	01	01	H1019_153_0	4		N	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	0		0				25		25	0		0	0		0
H1019	153	0	1	01	01	H1019_153_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	0		0				25		25	0		0	0		0
H1019	153	0	1	01	01	H1019_153_0	4		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H1019	153	0	1	01	01	H1019_153_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1019	153	0	1	01	01	H1019_153_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1019	154	0	1	01	01	H1019_154_0	5			Preferred Generic	4	11	3	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									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	0		0				25		25	0		0	0		0
H1019	154	0	1	01	01	H1019_154_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	0.00		0.00																									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	0		0				25		25	0		0	0		0
H1019	154	0	1	01	01	H1019_154_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	25		25				25		25	25		25	25		25
H1019	154	0	1	01	01	H1019_154_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	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	25		25				25		25	25		25	25		25
H1019	154	0	1	01	01	H1019_154_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	25						25			25			25		25
H1019	154	0	1	01	01	H1019_154_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	0		0				0		0	0		0	0		0
H1032	193	0	1	01	01	H1032_193_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	193	0	1	01	01	H1032_193_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	193	0	1	01	01	H1032_193_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.81	25	25	25				112.81	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	193	0	1	01	01	H1032_193_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											81.27	45	45	45				81.27	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	193	0	1	01	01	H1032_193_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	193	0	1	01	01	H1032_193_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	194	0	1	01	01	H1032_194_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	194	0	1	01	01	H1032_194_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.34	25	25	25				122.34	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	194	0	1	01	01	H1032_194_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.32	34	34	34				72.32	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	194	0	1	01	01	H1032_194_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	194	0	1	01	01	H1032_194_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	195	0	1	01	01	H1032_195_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	195	0	1	01	01	H1032_195_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											102.94	22	22	22				93.58	20	20	20											22	22					20	20			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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	20	20	20		22	22		20	20	22		22
H1032	195	0	1	01	01	H1032_195_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.43	40	40	40				47.08	26	26	26											40	40					26	26			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	195	0	1	01	01	H1032_195_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	195	0	1	01	01	H1032_195_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	196	0	1	01	01	H1032_196_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	196	0	1	01	01	H1032_196_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.22	25	25	25				122.22	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	196	0	1	01	01	H1032_196_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.83	31	31	31				78.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	196	0	1	01	01	H1032_196_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	196	0	1	01	01	H1032_196_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	198	0	1	01	01	H1032_198_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	198	0	1	01	01	H1032_198_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											117.48	25	25	25				117.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	198	0	1	01	01	H1032_198_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.04	50	50	50				75.04	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	198	0	1	01	01	H1032_198_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	198	0	1	01	01	H1032_198_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	199	0	1	01	01	H1032_199_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	199	0	1	01	01	H1032_199_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.03	25	25	25				129.03	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	199	0	1	01	01	H1032_199_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.30	33	33	33				77.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	199	0	1	01	01	H1032_199_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	199	0	1	01	01	H1032_199_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	200	0	1	01	01	H1032_200_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	200	0	1	01	01	H1032_200_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											111.90	25	25	25				111.90	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	200	0	1	01	01	H1032_200_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.19	47	47	47				77.50	46	46	46											47	47					46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	200	0	1	01	01	H1032_200_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	200	0	1	01	01	H1032_200_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	201	0	1	01	01	H1032_201_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	201	0	1	01	01	H1032_201_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.56	25	25	25				116.56	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	201	0	1	01	01	H1032_201_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											68.83	39	39	39				65.30	37	37	37											39	39					37	37			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	201	0	1	01	01	H1032_201_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	201	0	1	01	01	H1032_201_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	202	0	1	01	01	H1032_202_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					2.00	4.00	6.00												38.00	57.00					4.00	0.00				19.00				19.00			0.63	0.07				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	202	0	1	01	01	H1032_202_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	202	0	1	01	01	H1032_202_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											84.69	20	20	20				84.69	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1032	202	0	1	01	01	H1032_202_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	202	0	1	01	01	H1032_202_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	202	0	1	01	01	H1032_202_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	204	0	1	01	01	H1032_204_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	204	0	1	01	01	H1032_204_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											110.31	25	25	25				110.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	204	0	1	01	01	H1032_204_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											66.25	50	50	50				66.25	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	204	0	1	01	01	H1032_204_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	204	0	1	01	01	H1032_204_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	205	0	1	01	01	H1032_205_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	205	0	1	01	01	H1032_205_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.89	25	25	25				123.89	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	205	0	1	01	01	H1032_205_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											55.90	35	35	35				54.31	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	205	0	1	01	01	H1032_205_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	205	0	1	01	01	H1032_205_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	210	0	1	01	01	H1032_210_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	210	0	1	01	01	H1032_210_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.90	25	25	25				122.90	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	210	0	1	01	01	H1032_210_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.87	50	50	50				74.87	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	210	0	1	01	01	H1032_210_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	210	0	1	01	01	H1032_210_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	211	0	1	01	01	H1032_211_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	211	0	1	01	01	H1032_211_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.92	25	25	25				123.92	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	211	0	1	01	01	H1032_211_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											62.66	38	38	38				61.01	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	211	0	1	01	01	H1032_211_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	211	0	1	01	01	H1032_211_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	212	0	1	01	01	H1032_212_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	212	0	1	01	01	H1032_212_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											107.00	25	25	25				107.00	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	212	0	1	01	01	H1032_212_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.94	44	44	44				79.94	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	212	0	1	01	01	H1032_212_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	212	0	1	01	01	H1032_212_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	213	0	1	01	01	H1032_213_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	213	0	1	01	01	H1032_213_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.31	25	25	25				89.85	20	20	20											25	25					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	20	20	20		25	25		20	20	25		25
H1032	213	0	1	01	01	H1032_213_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.08	44	44	44				57.36	26	26	26											44	44					26	26			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	213	0	1	01	01	H1032_213_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	213	0	1	01	01	H1032_213_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1032	237	0	1	01	01	H1032_237_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1032	237	0	1	01	01	H1032_237_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											121.69	25	25	25				82.75	17	17	17											25	25					17	17			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	17	17	17		25	25		17	17	25		25
H1032	237	0	1	01	01	H1032_237_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.23	50	50	50				49.62	25	25	25											50	50					25	25			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	237	0	1	01	01	H1032_237_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	237	0	1	01	01	H1032_237_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	240	0	1	01	01	H1032_240_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	240	0	1	01	01	H1032_240_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	240	0	1	01	01	H1032_240_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.95	25	25	25				99.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	240	0	1	01	01	H1032_240_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	240	0	1	01	01	H1032_240_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	240	0	1	01	01	H1032_240_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00												4.00	6.00					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																														
H1032	241	0	1	01	01	H1032_241_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	241	0	1	01	01	H1032_241_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	241	0	1	01	01	H1032_241_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.95	25	25	25				99.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	241	0	1	01	01	H1032_241_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	241	0	1	01	01	H1032_241_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	241	0	1	01	01	H1032_241_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00												4.00	6.00					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																														
H1032	242	0	1	01	01	H1032_242_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	242	0	1	01	01	H1032_242_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	242	0	1	01	01	H1032_242_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.95	25	25	25				99.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	242	0	1	01	01	H1032_242_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	242	0	1	01	01	H1032_242_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	242	0	1	01	01	H1032_242_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								2.00	4.00	6.00					0.00	0.00	0.00												4.00	6.00					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																														
H1032	243	0	1	01	01	H1032_243_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	243	0	1	01	01	H1032_243_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	243	0	1	01	01	H1032_243_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											95.83	24	24	24				95.83	24	24	24											24	24					24	24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	24	24	24	24	24	24		24	24		24	24	24		24
H1032	243	0	1	01	01	H1032_243_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	243	0	1	01	01	H1032_243_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	243	0	1	01	01	H1032_243_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	1	1	01	01	H1032_244_1	10		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00												38.00	57.00					0.00	0.00				19.00				19.00			0.63	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	1	1	01	01	H1032_244_1	10		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					14.00	28.00	42.00												40.00	60.00					28.00	0.00				20.00				20.00			0.67	0.47				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	1	1	01	01	H1032_244_1	10		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.66	20	20	20				78.66	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1032	244	1	1	01	01	H1032_244_1	10		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	244	1	1	01	01	H1032_244_1	10		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	1	1	01	01	H1032_244_1	10		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	2	1	01	01	H1032_244_2	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00												38.00	57.00					0.00	0.00				19.00				19.00			0.63	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	2	1	01	01	H1032_244_2	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					14.00	28.00	42.00												40.00	60.00					28.00	0.00				20.00				20.00			0.67	0.47				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	2	1	01	01	H1032_244_2	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.66	20	20	20				78.66	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1032	244	2	1	01	01	H1032_244_2	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	244	2	1	01	01	H1032_244_2	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	244	2	1	01	01	H1032_244_2	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	1	1	01	01	H1032_245_1	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					1.00	2.00	3.00												38.00	57.00					2.00	0.00				19.00				19.00			0.63	0.03				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	1	1	01	01	H1032_245_1	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	1	1	01	01	H1032_245_1	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											80.76	20	20	20				80.76	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1032	245	1	1	01	01	H1032_245_1	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	245	1	1	01	01	H1032_245_1	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	1	1	01	01	H1032_245_1	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	2	1	01	01	H1032_245_2	10		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					1.00	2.00	3.00												38.00	57.00					2.00	0.00				19.00				19.00			0.63	0.03				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	2	1	01	01	H1032_245_2	10		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	2	1	01	01	H1032_245_2	10		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											80.76	20	20	20				80.76	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1032	245	2	1	01	01	H1032_245_2	10		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1032	245	2	1	01	01	H1032_245_2	10		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1032	245	2	1	01	01	H1032_245_2	10		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	5			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	1	2		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	25	25	25	0	0	0		0	0				25		25
H1035	002	0	1	02	01	H1035_002_0	5			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	1	2		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	25	25	25	0	0	0		0	0				25		25
H1035	002	0	1	02	01	H1035_002_0	5			Preferred Brand	4	11	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	25	25	25	25	25	25		25	25				25		25
H1035	002	0	1	02	01	H1035_002_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	101		1				31	62	93	1	1		62	93				31		31											120.90	25	25	25				68.44	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	25	25	25	25	25	25		25	25				25		25
H1035	002	0	1	02	01	H1035_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											524.51	25						272.39	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00			35.00									35.00		35.00	25			25									25		25
H1035	002	0	1	02	01	H1035_002_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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	017	0	1	01	01	H1035_017_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.18	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	21		21				21		21				21		21
H1035	017	0	1	01	01	H1035_017_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				52.15	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				990.44	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	25						25						25		25
H1035	017	0	1	01	01	H1035_017_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	019	0	1	01	01	H1035_019_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	019	0	1	01	01	H1035_019_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																														
H1035	019	0	1	01	01	H1035_019_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.94	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	21		21				21		21				21		21
H1035	019	0	1	01	01	H1035_019_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				46.02	30		30																		30		30															30			30								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	25		25				25		25				25		25
H1035	019	0	1	01	01	H1035_019_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1100.02	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	25						25						25		25
H1035	019	0	1	01	01	H1035_019_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	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	0.00		0.00																			0.00		0.00																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 Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				42.19	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	21		21				21		21				21		21
H1035	020	0	1	01	01	H1035_020_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				47.40	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1253.91	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	25						25						25		25
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	0.00		0.00																			0.00		0.00																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 Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				42.88	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	21		21				21		21				21		21
H1035	021	0	1	01	01	H1035_021_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				49.46	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1276.25	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	25						25						25		25
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	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	022	0	1	01	01	H1035_022_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																														
H1035	022	0	1	01	01	H1035_022_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				44.81	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	21		21				21		21				21		21
H1035	022	0	1	01	01	H1035_022_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				46.81	30		30																		30		30															30			30								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	25		25				25		25				25		25
H1035	022	0	1	01	01	H1035_022_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				867.10	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	25						25						25		25
H1035	022	0	1	01	01	H1035_022_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	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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	025	0	1	01	01	H1035_025_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				49.85	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	21		21				21		21				21		21
H1035	025	0	1	01	01	H1035_025_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				48.88	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				884.08	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	25						25						25		25
H1035	025	0	1	01	01	H1035_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																														
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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	026	0	1	01	01	H1035_026_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				44.74	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	21		21				21		21				21		21
H1035	026	0	1	01	01	H1035_026_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				45.93	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1309.51	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	25						25						25		25
H1035	026	0	1	01	01	H1035_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																														
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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	033	0	1	01	01	H1035_033_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				47.28	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	21		21				21		21				21		21
H1035	033	0	1	01	01	H1035_033_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				40.14	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1174.69	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	25						25						25		25
H1035	033	0	1	01	01	H1035_033_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	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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	034	0	1	01	01	H1035_034_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				42.94	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	21		21				21		21				21		21
H1035	034	0	1	01	01	H1035_034_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				45.28	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1084.12	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1035	034	0	1	01	01	H1035_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																														
H1035	040	0	1	01	01	H1035_040_0	5			Preferred Generic	4	01	1	2	1	1		111	01	101		1				31	62	93	1	2		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	25	25	25	0	0	0		0	0				25		25
H1035	040	0	1	01	01	H1035_040_0	5			Generic	4	01	1	2	2	1		111	01	101		1				31	62	93	1	2		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	25	25	25	25	25	25		25	25				25		25
H1035	040	0	1	01	01	H1035_040_0	5			Preferred Brand	4	11	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	25	25	25	25	25	25		25	25				25		25
H1035	040	0	1	01	01	H1035_040_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	101		1				31	62	93	1	1		62	93				31		31											158.33	25	25	25				68.86	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	25	25	25	25	25	25		25	25				25		25
H1035	040	0	1	01	01	H1035_040_0	5			Specialty Tier	4	11	1	1	5	1		010	01	000		1				31											31		31											473.22	25						212.40	25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00			35.00									35.00		35.00	25			25									25		25
H1035	040	0	1	01	01	H1035_040_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	043	0	1	01	01	H1035_043_0	7			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	043	0	1	01	01	H1035_043_0	7			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1035	043	0	1	01	01	H1035_043_0	7			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				45.85	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	21		21				21		21				21		21
H1035	043	0	1	01	01	H1035_043_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				46.18	30		30																		30		30															30			30								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	25		25				25		25				25		25
H1035	043	0	1	01	01	H1035_043_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1524.85	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	25						25						25		25
H1035	043	0	1	01	01	H1035_043_0	7			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	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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	045	0	1	01	01	H1035_045_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				49.20	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	21		21				21		21				21		21
H1035	045	0	1	01	01	H1035_045_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				45.79	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1300.27	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	25						25						25		25
H1035	045	0	1	01	01	H1035_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																														
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, Select Care Drugs																														
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, Select Care Drugs																														
H1035	048	0	1	01	01	H1035_048_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.32	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	21		21				21		21				21		21
H1035	048	0	1	01	01	H1035_048_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				43.59	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1262.82	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	25						25						25		25
H1035	048	0	1	01	01	H1035_048_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	052	0	1	01	01	H1035_052_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	052	0	1	01	01	H1035_052_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1035	052	0	1	01	01	H1035_052_0	9			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.23	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	21		21				21		21				21		21
H1035	052	0	1	01	01	H1035_052_0	9			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				41.88	30		30																		30		30															30			30								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	25		25				25		25				25		25
H1035	052	0	1	01	01	H1035_052_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1126.34	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	25						25						25		25
H1035	052	0	1	01	01	H1035_052_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																														
H1036	025	0	1	01	01	H1036_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	0		0				25		25	0		0	0		0
H1036	025	0	1	01	01	H1036_025_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	0		0				25		25	0		0	0		0
H1036	025	0	1	01	01	H1036_025_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	5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00	25		25				25		25	25		25	25		25
H1036	025	0	1	01	01	H1036_025_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	025	0	1	01	01	H1036_025_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	25						25			25			25		25
H1036	044	0	1	01	01	H1036_044_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	0		0				25		25	0		0	0		0
H1036	044	0	1	01	01	H1036_044_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	0		0				25		25	0		0	0		0
H1036	044	0	1	01	01	H1036_044_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	25		25				25		25	25		25	25		25
H1036	044	0	1	01	01	H1036_044_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	044	0	1	01	01	H1036_044_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	25						25			25			25		25
H1036	054	0	1	01	01	H1036_054_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	0		0				0		0	0		0	0		0
H1036	054	0	1	01	01	H1036_054_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																									4.00		12.00				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				4.00		12.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	054	0	1	01	01	H1036_054_0	4			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	0		0				25		25	0		0	0		0
H1036	054	0	1	01	01	H1036_054_0	4			Non-Preferred Drug	4	11	1	2	4	1	110		01		110	1	30		100				2	2				30		100	30		31	50.00		150.00																									50.00		150.00				50.00		140.00				50.00				50.00		1.67				1.67	1.67	1.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	054	0	1	01	01	H1036_054_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	25						25			25			25		25
H1036	062	0	1	01	01	H1036_062_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	0		0				0		0	0		0	0		0
H1036	062	0	1	01	01	H1036_062_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	0		0				25		25	0		0	0		0
H1036	062	0	1	01	01	H1036_062_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																									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	25		25				25		25	25		25	25		25
H1036	062	0	1	01	01	H1036_062_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	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	25		25				25		25	25		25	25		25
H1036	062	0	1	01	01	H1036_062_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	25						25			25			25		25
H1036	065	0	1	01	01	H1036_065_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																									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	0		0				25		25	0		0	0		0
H1036	065	0	1	01	01	H1036_065_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	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	065	0	1	01	01	H1036_065_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	5.00		15.00				35.00		105.00	5.00		5.00	5.00		5.00	25		25				25		25	25		25	25		25
H1036	065	0	1	01	01	H1036_065_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	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	25		25				25		25	25		25	25		25
H1036	065	0	1	01	01	H1036_065_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	25						25			25			25		25
H1036	068	0	1	01	01	H1036_068_0	2			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	0		0				25		25	0		0	0		0
H1036	068	0	1	01	01	H1036_068_0	2			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	0		0				25		25	0		0	0		0
H1036	068	0	1	01	01	H1036_068_0	2			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	25		25				25		25	25		25	25		25
H1036	068	0	1	01	01	H1036_068_0	2			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	25		25				25		25	25		25	25		25
H1036	068	0	1	01	01	H1036_068_0	2			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	25						25			25			25		25
H1036	074	0	1	01	01	H1036_074_0	2			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	0		0				25		25	0		0	0		0
H1036	074	0	1	01	01	H1036_074_0	2			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	0		0				25		25	0		0	0		0
H1036	074	0	1	01	01	H1036_074_0	2			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	25		25				25		25	25		25	25		25
H1036	074	0	1	01	01	H1036_074_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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	25		25				25		25	25		25	25		25
H1036	074	0	1	01	01	H1036_074_0	2			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	25						25			25			25		25
H1036	077	0	1	01	01	H1036_077_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	0		0				25		25	0		0	0		0
H1036	077	0	1	01	01	H1036_077_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	0		0				25		25	0		0	0		0
H1036	077	0	1	01	01	H1036_077_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	077	0	1	01	01	H1036_077_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	25		25				25		25	25		25	25		25
H1036	077	0	1	01	01	H1036_077_0	4		N	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	25						25			25			25		25
H1036	102	0	1	01	01	H1036_102_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	0		0				25		25	0		0	0		0
H1036	102	0	1	01	01	H1036_102_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	0		0				25		25	0		0	0		0
H1036	102	0	1	01	01	H1036_102_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	102	0	1	01	01	H1036_102_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	102	0	1	01	01	H1036_102_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				59.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1036	137	0	1	02	01	H1036_137_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	0		0				25		25	0		0	0		0
H1036	137	0	1	02	01	H1036_137_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1036	137	0	1	02	01	H1036_137_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	25		25				25		25	25		25	25		25
H1036	137	0	1	02	01	H1036_137_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	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	25		25				25		25	25		25	25		25
H1036	137	0	1	02	01	H1036_137_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	25						25			25			25		25
H1036	143	0	1	01	01	H1036_143_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	0		0				25		25	0		0	0		0
H1036	143	0	1	01	01	H1036_143_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1036	143	0	1	01	01	H1036_143_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	25		25				25		25	25		25	25		25
H1036	143	0	1	01	01	H1036_143_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	143	0	1	01	01	H1036_143_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	25						25			25			25		25
H1036	146	0	1	01	01	H1036_146_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	0		0				25		25	0		0	0		0
H1036	146	0	1	01	01	H1036_146_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	0		0				25		25	0		0	0		0
H1036	146	0	1	01	01	H1036_146_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	25		25				25		25	25		25	25		25
H1036	146	0	1	01	01	H1036_146_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	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	25		25				25		25	25		25	25		25
H1036	146	0	1	01	01	H1036_146_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	25						25			25			25		25
H1036	151	0	1	01	01	H1036_151_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	0		0				25		25	0		0	0		0
H1036	151	0	1	01	01	H1036_151_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	25		25				25		25	25		0	25		25
H1036	151	0	1	01	01	H1036_151_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	25		25				25		25	25		25	25		25
H1036	151	0	1	01	01	H1036_151_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	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	25		25				25		25	25		25	25		25
H1036	151	0	1	01	01	H1036_151_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	25						25			25			25		25
H1036	153	0	1	01	01	H1036_153_0	2			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	0		0				25		25	0		0	0		0
H1036	153	0	1	01	01	H1036_153_0	2			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	25		25				25		25	25		0	25		25
H1036	153	0	1	01	01	H1036_153_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	153	0	1	01	01	H1036_153_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H1036	153	0	1	01	01	H1036_153_0	2			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	25						25			25			25		25
H1036	157	0	1	01	01	H1036_157_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	0		0				25		25	0		0	0		0
H1036	157	0	1	01	01	H1036_157_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	0		0				25		25	0		0	0		0
H1036	157	0	1	01	01	H1036_157_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	25		25				25		25	25		25	25		25
H1036	157	0	1	01	01	H1036_157_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	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	25		25				25		25	25		25	25		25
H1036	157	0	1	01	01	H1036_157_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	25						25			25			25		25
H1036	167	0	1	01	01	H1036_167_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	0		0				25		25	0		0	0		0
H1036	167	0	1	01	01	H1036_167_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	0		0				25		25	0		0	0		0
H1036	167	0	1	01	01	H1036_167_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	167	0	1	01	01	H1036_167_0	5		N	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	25		25				25		25	25		25	25		25
H1036	167	0	1	01	01	H1036_167_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	25						25			25			25		25
H1036	209	0	1	01	01	H1036_209_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	0		0				25		25	0		0	0		0
H1036	209	0	1	01	01	H1036_209_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	0		0				25		25	0		0	0		0
H1036	209	0	1	01	01	H1036_209_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	209	0	1	01	01	H1036_209_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	209	0	1	01	01	H1036_209_0	5		N	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	25						25			25			25		25
H1036	210	0	1	01	01	H1036_210_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	0		0				25		25	0		0	0		0
H1036	210	0	1	01	01	H1036_210_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	0		0				25		25	0		0	0		0
H1036	210	0	1	01	01	H1036_210_0	5		N	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	25		25				25		25	25		25	25		25
H1036	210	0	1	01	01	H1036_210_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	210	0	1	01	01	H1036_210_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	213	0	1	01	01	H1036_213_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	0		0				25		25	0		0	0		0
H1036	213	0	1	01	01	H1036_213_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	0		0				25		25	0		0	0		0
H1036	213	0	1	01	01	H1036_213_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	213	0	1	01	01	H1036_213_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H1036	213	0	1	01	01	H1036_213_0	5		N	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	25						25			25			25		25
H1036	214	0	1	01	01	H1036_214_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	0		0				25		25	0		0	0		0
H1036	214	0	1	01	01	H1036_214_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	0		0				25		25	0		0	0		0
H1036	214	0	1	01	01	H1036_214_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	214	0	1	01	01	H1036_214_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H1036	214	0	1	01	01	H1036_214_0	5		N	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	25						25			25			25		25
H1036	217	0	1	01	01	H1036_217_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	0		0				25		25	0		0	0		0
H1036	217	0	1	01	01	H1036_217_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	0		0				25		25	0		0	0		0
H1036	217	0	1	01	01	H1036_217_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	35.00		105.00																									47.00		141.00				35.00		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	25		25				25		25	25		25	25		25
H1036	217	0	1	01	01	H1036_217_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	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	25		25				25		25	25		25	25		25
H1036	217	0	1	01	01	H1036_217_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	25						25			25			25		25
H1036	222	0	1	01	01	H1036_222_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	0		0				25		25	0		0	0		0
H1036	222	0	1	01	01	H1036_222_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	0		0				25		25	0		0	0		0
H1036	222	0	1	01	01	H1036_222_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	222	0	1	01	01	H1036_222_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	222	0	1	01	01	H1036_222_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	25						25			25			25		25
H1036	226	0	1	01	01	H1036_226_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	0		0				25		25	0		0	0		0
H1036	226	0	1	01	01	H1036_226_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	0		0				25		25	0		0	0		0
H1036	226	0	1	01	01	H1036_226_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	226	0	1	01	01	H1036_226_0	5		N	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	25		25				25		25	25		25	25		25
H1036	226	0	1	01	01	H1036_226_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	25						25			25			25		25
H1036	229	0	1	01	01	H1036_229_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	0		0				25		25	0		0	0		0
H1036	229	0	1	01	01	H1036_229_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	0		0				25		25	0		0	0		0
H1036	229	0	1	01	01	H1036_229_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	25		25				25		25	25		25	25		25
H1036	229	0	1	01	01	H1036_229_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	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	25		25				25		25	25		25	25		25
H1036	229	0	1	01	01	H1036_229_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	25						25			25			25		25
H1036	230	0	1	01	01	H1036_230_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	0		0				25		25	0		0	0		0
H1036	230	0	1	01	01	H1036_230_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																									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	0		0				25		25	0		0	0		0
H1036	230	0	1	01	01	H1036_230_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	25		25				25		25	25		25	25		25
H1036	230	0	1	01	01	H1036_230_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	25		25				25		25	25		25	25		25
H1036	230	0	1	01	01	H1036_230_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	25						25			25			25		25
H1036	233	0	1	02	01	H1036_233_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	0		0				25		25	0		0	0		0
H1036	233	0	1	02	01	H1036_233_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1036	233	0	1	02	01	H1036_233_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	25		25				25		25	25		25	25		25
H1036	233	0	1	02	01	H1036_233_0	3			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	25		25				25		25	25		25	25		25
H1036	233	0	1	02	01	H1036_233_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	25						25			25			25		25
H1036	234	0	1	01	01	H1036_234_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	0		0				25		25	0		0	0		0
H1036	234	0	1	01	01	H1036_234_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	25		25				25		25	25		0	25		25
H1036	234	0	1	01	01	H1036_234_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	234	0	1	01	01	H1036_234_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				57.00	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	25		25				25		25	25		25	25		25
H1036	234	0	1	01	01	H1036_234_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	234	0	1	01	01	H1036_234_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	0		0				0		0	0		0	0		0
H1036	235	0	1	01	01	H1036_235_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	0		0				25		25	0		0	0		0
H1036	235	0	1	01	01	H1036_235_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	0		0				25		25	0		0	0		0
H1036	235	0	1	01	01	H1036_235_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	235	0	1	01	01	H1036_235_0	4		N	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	25		25				25		25	25		25	25		25
H1036	235	0	1	01	01	H1036_235_0	4		N	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	25						25			25			25		25
H1036	236	0	1	01	01	H1036_236_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	0		0				25		25	0		0	0		0
H1036	236	0	1	01	01	H1036_236_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	0		0				25		25	0		0	0		0
H1036	236	0	1	01	01	H1036_236_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	25		25				25		25	25		25	25		25
H1036	236	0	1	01	01	H1036_236_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	236	0	1	01	01	H1036_236_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	25						25			25			25		25
H1036	265	1	1	01	01	H1036_265_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	0		0				25		25	0		0	0		0
H1036	265	1	1	01	01	H1036_265_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	0		0				25		25	0		0	0		0
H1036	265	1	1	01	01	H1036_265_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	25		25				25		25	25		25	25		25
H1036	265	1	1	01	01	H1036_265_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1036	265	1	1	01	01	H1036_265_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				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		35.00	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1036	266	0	1	01	01	H1036_266_0	2			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	0		0				0		0	0		0	0		0
H1036	266	0	1	01	01	H1036_266_0	2			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	0		0				0		0	0		0	0		0
H1036	266	0	1	01	01	H1036_266_0	2			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	25		25				25		25	25		25	25		25
H1036	266	0	1	01	01	H1036_266_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1036	266	0	1	01	01	H1036_266_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				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		35.00	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1036	270	0	1	01	01	H1036_270_0	2			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	0		0				25		25	0		0	0		0
H1036	270	0	1	01	01	H1036_270_0	2			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	0		0				25		25	0		0	0		0
H1036	270	0	1	01	01	H1036_270_0	2			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	25		25				25		25	25		25	25		25
H1036	270	0	1	01	01	H1036_270_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1036	270	0	1	01	01	H1036_270_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	25						25			25			25		25
H1036	271	0	1	01	01	H1036_271_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	0		0				25		25	0		0	0		0
H1036	271	0	1	01	01	H1036_271_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	0		0				25		25	0		0	0		0
H1036	271	0	1	01	01	H1036_271_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	25		25				25		25	25		25	25		25
H1036	271	0	1	01	01	H1036_271_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H1036	271	0	1	01	01	H1036_271_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	25						25			25			25		25
H1036	278	0	1	01	01	H1036_278_0	2			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	0		0				25		25	0		0	0		0
H1036	278	0	1	01	01	H1036_278_0	2			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	0		0				25		25	0		0	0		0
H1036	278	0	1	01	01	H1036_278_0	2			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	25		25				25		25	25		25	25		25
H1036	278	0	1	01	01	H1036_278_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				46.00	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	25		25				25		25	25		25	25		25
H1036	278	0	1	01	01	H1036_278_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
H1036	280	0	1	01	01	H1036_280_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H1036	285	0	1	01	01	H1036_285_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	0		0				25		25	0		0	0		0
H1036	285	0	1	01	01	H1036_285_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	0		0				25		25	0		0	0		0
H1036	285	0	1	01	01	H1036_285_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	285	0	1	01	01	H1036_285_0	5		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	25		25				25		25	25		25	25		25
H1036	285	0	1	01	01	H1036_285_0	5		N	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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H1036	286	0	1	01	01	H1036_286_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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1036	292	0	1	01	01	H1036_292_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	0		0				25		25	0		0	0		0
H1036	292	0	1	01	01	H1036_292_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	25		25				25		25	25		0	25		25
H1036	292	0	1	01	01	H1036_292_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	35.00		105.00																									47.00		141.00				35.00		70.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	292	0	1	01	01	H1036_292_0	5			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	292	0	1	01	01	H1036_292_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	25						25			25			25		25
H1036	292	0	1	01	01	H1036_292_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	0		0				0		0	0		0	0		0
H1036	297	0	1	01	01	H1036_297_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	0		0				0		0	0		0	0		0
H1036	297	0	1	01	01	H1036_297_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	0		0				25		25	0		0	0		0
H1036	297	0	1	01	01	H1036_297_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	297	0	1	01	01	H1036_297_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				56.00	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	25		25				25		25	25		25	25		25
H1036	297	0	1	01	01	H1036_297_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	25						25			25			25		25
H1036	297	0	1	01	01	H1036_297_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	0		0				0		0	0		0	0		0
H1036	298	0	1	01	01	H1036_298_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	0		0				25		25	0		0	0		0
H1036	298	0	1	01	01	H1036_298_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	25		25				25		25	25		0	25		25
H1036	298	0	1	01	01	H1036_298_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	35.00		105.00																									47.00		141.00				35.00		70.00				35.00				35.00		1.17				1.57	1.17	1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	298	0	1	01	01	H1036_298_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	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	25		25				25		25	25		25	25		25
H1036	298	0	1	01	01	H1036_298_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H1036	298	0	1	01	01	H1036_298_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	0		0				0		0	0		0	0		0
H1036	299	0	1	01	01	H1036_299_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	0		0				25		25	0		0	0		0
H1036	299	0	1	01	01	H1036_299_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	299	0	1	01	01	H1036_299_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, Select Care Drugs	30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00	25		25				25		25	25		25	25		25
H1036	299	0	1	01	01	H1036_299_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H1036	299	0	1	01	01	H1036_299_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	25						25			25			25		25
H1036	299	0	1	01	01	H1036_299_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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
H1036	300	0	1	01	01	H1036_300_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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				61.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1036	301	0	1	01	01	H1036_301_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	0		0				25		25	0		0	0		0
H1036	301	0	1	01	01	H1036_301_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	301	0	1	01	01	H1036_301_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, Select Care Drugs	30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00	25		25				25		25	25		25	25		25
H1036	301	0	1	01	01	H1036_301_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H1036	301	0	1	01	01	H1036_301_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	301	0	1	01	01	H1036_301_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	0		0				0		0	0		0	0		0
H1036	302	0	1	01	01	H1036_302_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	0		0				25		25	0		0	0		0
H1036	302	0	1	01	01	H1036_302_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	302	0	1	01	01	H1036_302_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	302	0	1	01	01	H1036_302_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
H1036	302	0	1	01	01	H1036_302_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	25						25			25			25		25
H1036	302	0	1	01	01	H1036_302_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	0		0				0		0	0		0	0		0
H1036	304	0	1	01	01	H1036_304_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	0		0				25		25	0		0	0		0
H1036	304	0	1	01	01	H1036_304_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	0		0				25		25	0		0	0		0
H1036	304	0	1	01	01	H1036_304_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	304	0	1	01	01	H1036_304_0	5		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	25		25				25		25	25		25	25		25
H1036	304	0	1	01	01	H1036_304_0	5		N	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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				55.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H1036	306	0	1	01	01	H1036_306_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	0		0				25		25	0		0	0		0
H1036	306	0	1	01	01	H1036_306_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, Select Care Drugs	10.00		30.00				20.00		60.00	10.00		0.00	10.00		10.00	25		25				25		25	25		0	25		25
H1036	306	0	1	01	01	H1036_306_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	306	0	1	01	01	H1036_306_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	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	25		25				25		25	25		25	25		25
H1036	306	0	1	01	01	H1036_306_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	25						25			25			25		25
H1036	306	0	1	01	01	H1036_306_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	0		0				0		0	0		0	0		0
H1036	307	0	1	01	01	H1036_307_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	0		0				25		25	0		0	0		0
H1036	307	0	1	01	01	H1036_307_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	0		0				25		25	0		0	0		0
H1036	307	0	1	01	01	H1036_307_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	307	0	1	01	01	H1036_307_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H1036	307	0	1	01	01	H1036_307_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	25						25			25			25		25
H1036	308	0	1	01	01	H1036_308_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	0		0				25		25	0		0	0		0
H1036	308	0	1	01	01	H1036_308_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	25		25				25		25	25		0	25		25
H1036	308	0	1	01	01	H1036_308_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	308	0	1	01	01	H1036_308_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				57.00	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	25		25				25		25	25		25	25		25
H1036	308	0	1	01	01	H1036_308_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H1036	308	0	1	01	01	H1036_308_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	0		0				0		0	0		0	0		0
H1036	310	0	1	01	01	H1036_310_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	0		0				25		25	0		0	0		0
H1036	310	0	1	01	01	H1036_310_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	0		0				25		25	0		0	0		0
H1036	310	0	1	01	01	H1036_310_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		10.00				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		10.00	5.00		5.00	25		25				25		25	25		25	25		25
H1036	310	0	1	01	01	H1036_310_0	5			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	310	0	1	01	01	H1036_310_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	25						25			25			25		25
H1036	310	0	1	01	01	H1036_310_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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
H1036	311	0	1	01	01	H1036_311_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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		10.00				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		10.00	5.00		5.00	25		25				25		25	25		25	25		25
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				63.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1036	312	0	1	01	01	H1036_312_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	0		0				25		25	0		0	0		0
H1036	312	0	1	01	01	H1036_312_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	312	0	1	01	01	H1036_312_0	6			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	312	0	1	01	01	H1036_312_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	25		25				25		25	25		25	25		25
H1036	312	0	1	01	01	H1036_312_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	312	0	1	01	01	H1036_312_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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
H1036	313	0	1	01	01	H1036_313_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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				60.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1036	314	0	1	01	01	H1036_314_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	0		0				25		25	0		0	0		0
H1036	314	0	1	01	01	H1036_314_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	0		0				25		25	0		0	0		0
H1036	314	0	1	01	01	H1036_314_0	5		N	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	25		25				25		25	25		25	25		25
H1036	314	0	1	01	01	H1036_314_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	314	0	1	01	01	H1036_314_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	315	0	1	01	01	H1036_315_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	0		0				25		25	0		0	0		0
H1036	315	0	1	01	01	H1036_315_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	315	0	1	01	01	H1036_315_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	315	0	1	01	01	H1036_315_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	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	25		25				25		25	25		25	25		25
H1036	315	0	1	01	01	H1036_315_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	25						25			25			25		25
H1036	315	0	1	01	01	H1036_315_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	0		0				0		0	0		0	0		0
H1036	316	0	1	01	01	H1036_316_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	0		0				25		25	0		0	0		0
H1036	316	0	1	01	01	H1036_316_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	316	0	1	01	01	H1036_316_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	316	0	1	01	01	H1036_316_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	25		25				25		25	25		25	25		25
H1036	316	0	1	01	01	H1036_316_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	25						25			25			25		25
H1036	316	0	1	01	01	H1036_316_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	0		0				0		0	0		0	0		0
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	0		0				25		25	0		0	0		0
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	0.00		0.00																									20.00		60.00				0.00		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	0		0				25		25	0		0	0		0
H1036	317	0	1	01	01	H1036_317_0	4			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H1036	317	0	1	01	01	H1036_317_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				46.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H1036	318	0	1	02	01	H1036_318_0	2			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	0		0				25		25	0		0	0		0
H1036	318	0	1	02	01	H1036_318_0	2			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	25		25				25		25	25		0	25		25
H1036	318	0	1	02	01	H1036_318_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	318	0	1	02	01	H1036_318_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	46		46																								46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	318	0	1	02	01	H1036_318_0	2			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	25						25			25			25		25
H1036	319	0	1	01	01	H1036_319_0	2			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	0		0				25		25	0		0	0		0
H1036	319	0	1	01	01	H1036_319_0	2			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	25		25				25		25	25		0	25		25
H1036	319	0	1	01	01	H1036_319_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	319	0	1	01	01	H1036_319_0	2			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	25		25				25		25	25		25	25		25
H1036	319	0	1	01	01	H1036_319_0	2			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	25						25			25			25		25
H1036	320	0	1	01	01	H1036_320_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	0		0				25		25	0		0	0		0
H1036	320	0	1	01	01	H1036_320_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	0		0				25		25	0		0	0		0
H1036	320	0	1	01	01	H1036_320_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	320	0	1	01	01	H1036_320_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	320	0	1	01	01	H1036_320_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	25						25			25			25		25
H1036	321	0	1	01	01	H1036_321_0	2			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	0		0				25		25	0		0	0		0
H1036	321	0	1	01	01	H1036_321_0	2			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	25		25				25		25	25		0	25		25
H1036	321	0	1	01	01	H1036_321_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	321	0	1	01	01	H1036_321_0	2			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	25		25				25		25	25		25	25		25
H1036	321	0	1	01	01	H1036_321_0	2			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	25						25			25			25		25
H1036	322	0	1	01	01	H1036_322_0	2			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	0		0				25		25	0		0	0		0
H1036	322	0	1	01	01	H1036_322_0	2			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	25		25				25		25	25		0	25		25
H1036	322	0	1	01	01	H1036_322_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	322	0	1	01	01	H1036_322_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H1036	322	0	1	01	01	H1036_322_0	2			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	25						25			25			25		25
H1036	323	0	1	01	01	H1036_323_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	0		0				25		25	0		0	0		0
H1036	323	0	1	01	01	H1036_323_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1036	323	0	1	01	01	H1036_323_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	25		25				25		25	25		25	25		25
H1036	323	0	1	01	01	H1036_323_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	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	25		25				25		25	25		25	25		25
H1036	323	0	1	01	01	H1036_323_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	25						25			25			25		25
H1036	324	0	1	01	01	H1036_324_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	0		0				25		25	0		0	0		0
H1036	324	0	1	01	01	H1036_324_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	0		0				25		25	0		0	0		0
H1036	324	0	1	01	01	H1036_324_0	4		N	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	0		0				25		25	0		0	0		0
H1036	324	0	1	01	01	H1036_324_0	4		N	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	25		25				25		25	25		25	25		25
H1036	324	0	1	01	01	H1036_324_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	25						25			25			25		25
H1036	325	0	1	01	01	H1036_325_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	0		0				25		25	0		0	0		0
H1036	325	0	1	01	01	H1036_325_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	0		0				25		25	0		0	0		0
H1036	325	0	1	01	01	H1036_325_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	325	0	1	01	01	H1036_325_0	4		N	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	25		25				25		25	25		25	25		25
H1036	325	0	1	01	01	H1036_325_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	25						25			25			25		25
H1036	326	0	1	01	01	H1036_326_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	0		0				25		25	0		0	0		0
H1036	326	0	1	01	01	H1036_326_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	0		0				25		25	0		0	0		0
H1036	326	0	1	01	01	H1036_326_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	326	0	1	01	01	H1036_326_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	326	0	1	01	01	H1036_326_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	25						25			25			25		25
H1036	327	0	1	01	01	H1036_327_0	2			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	0		0				25		25	0		0	0		0
H1036	327	0	1	01	01	H1036_327_0	2			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	25		25				25		25	25		0	25		25
H1036	327	0	1	01	01	H1036_327_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	327	0	1	01	01	H1036_327_0	2			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	25		25				25		25	25		25	25		25
H1036	327	0	1	01	01	H1036_327_0	2			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	25						25			25			25		25
H1036	328	0	1	01	01	H1036_328_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	0		0				25		25	0		0	0		0
H1036	328	0	1	01	01	H1036_328_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	0		0				25		25	0		0	0		0
H1036	328	0	1	01	01	H1036_328_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	328	0	1	01	01	H1036_328_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	328	0	1	01	01	H1036_328_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	25						25			25			25		25
H1036	329	0	1	01	01	H1036_329_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	0		0				25		25	0		0	0		0
H1036	329	0	1	01	01	H1036_329_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	0		0				25		25	0		0	0		0
H1036	329	0	1	01	01	H1036_329_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	329	0	1	01	01	H1036_329_0	4		N	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	25		25				25		25	25		25	25		25
H1036	329	0	1	01	01	H1036_329_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	25						25			25			25		25
H1036	330	0	1	01	01	H1036_330_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	0		0				25		25	0		0	0		0
H1036	330	0	1	01	01	H1036_330_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	330	0	1	01	01	H1036_330_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	330	0	1	01	01	H1036_330_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	330	0	1	01	01	H1036_330_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	25						25			25			25		25
H1036	330	0	1	01	01	H1036_330_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	0		0				25		25	0		0	0		0
H1036	331	0	1	01	01	H1036_331_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	0		0				25		25	0		0	0		0
H1036	331	0	1	01	01	H1036_331_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	0		0				25		25	0		0	0		0
H1036	331	0	1	01	01	H1036_331_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	331	0	1	01	01	H1036_331_0	4		N	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	25		25				25		25	25		25	25		25
H1036	331	0	1	01	01	H1036_331_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	25						25			25			25		25
H1036	332	0	1	01	01	H1036_332_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	0		0				25		25	0		0	0		0
H1036	332	0	1	01	01	H1036_332_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	0		0				25		25	0		0	0		0
H1036	332	0	1	01	01	H1036_332_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	25		25				25		25	25		25	25		25
H1036	332	0	1	01	01	H1036_332_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	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	25		25				25		25	25		25	25		25
H1036	332	0	1	01	01	H1036_332_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	25						25			25			25		25
H1036	333	0	1	01	01	H1036_333_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	0		0				25		25	0		0	0		0
H1036	333	0	1	01	01	H1036_333_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1036	333	0	1	01	01	H1036_333_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	25		25				25		25	25		25	25		25
H1036	333	0	1	01	01	H1036_333_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H1036	333	0	1	01	01	H1036_333_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	25						25			25			25		25
H1036	334	0	1	01	01	H1036_334_0	2			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	0		0				25		25	0		0	0		0
H1036	334	0	1	01	01	H1036_334_0	2			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	0		0				25		25	0		0	0		0
H1036	334	0	1	01	01	H1036_334_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1036	334	0	1	01	01	H1036_334_0	2			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	25		25				25		25	25		25	25		25
H1036	334	0	1	01	01	H1036_334_0	2			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	25						25			25			25		25
H1036	335	1	1	02	01	H1036_335_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	0		0				25		25	0		0	0		0
H1036	335	1	1	02	01	H1036_335_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	25		25				25		25	25		0	25		25
H1036	335	1	1	02	01	H1036_335_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	25		25				25		25	25		25	25		25
H1036	335	1	1	02	01	H1036_335_1	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	25		25				25		25	25		25	25		25
H1036	335	1	1	02	01	H1036_335_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	25						25			25			25		25
H1036	335	2	1	02	01	H1036_335_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	0		0				25		25	0		0	0		0
H1036	335	2	1	02	01	H1036_335_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	25		25				25		25	25		0	25		25
H1036	335	2	1	02	01	H1036_335_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	25		25				25		25	25		25	25		25
H1036	335	2	1	02	01	H1036_335_2	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	25		25				25		25	25		25	25		25
H1036	335	2	1	02	01	H1036_335_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	25						25			25			25		25
H1036	336	0	1	01	01	H1036_336_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	0		0				25		25	0		0	0		0
H1036	336	0	1	01	01	H1036_336_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	336	0	1	01	01	H1036_336_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		90.00				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		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	336	0	1	01	01	H1036_336_0	3			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	336	0	1	01	01	H1036_336_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	336	0	1	01	01	H1036_336_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	0		0				0		0	0		0	0		0
H1036	337	0	1	01	01	H1036_337_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	0		0				25		25	0		0	0		0
H1036	337	0	1	01	01	H1036_337_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	337	0	1	01	01	H1036_337_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	337	0	1	01	01	H1036_337_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	337	0	1	01	01	H1036_337_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	25						25			25			25		25
H1036	337	0	1	01	01	H1036_337_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	0		0				0		0	0		0	0		0
H1036	338	0	1	01	01	H1036_338_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	0		0				25		25	0		0	0		0
H1036	338	0	1	01	01	H1036_338_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1036	338	0	1	01	01	H1036_338_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		90.00				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		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	338	0	1	01	01	H1036_338_0	3			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	338	0	1	01	01	H1036_338_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	338	0	1	01	01	H1036_338_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	0		0				0		0	0		0	0		0
H1036	339	0	1	01	01	H1036_339_0	3		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	0		0				25		25	0		0	0		0
H1036	339	0	1	01	01	H1036_339_0	3		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	0		0				25		25	0		0	0		0
H1036	339	0	1	01	01	H1036_339_0	3		N	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	25		25				25		25	25		25	25		25
H1036	339	0	1	01	01	H1036_339_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	339	0	1	01	01	H1036_339_0	3		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	340	0	1	01	01	H1036_340_0	3		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	0		0				25		25	0		0	0		0
H1036	340	0	1	01	01	H1036_340_0	3		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	0		0				25		25	0		0	0		0
H1036	340	0	1	01	01	H1036_340_0	3		N	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	25		25				25		25	25		25	25		25
H1036	340	0	1	01	01	H1036_340_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	340	0	1	01	01	H1036_340_0	3		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1036	341	0	1	01	01	H1036_341_0	3		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	0		0				25		25	0		0	0		0
H1036	341	0	1	01	01	H1036_341_0	3		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	0		0				25		25	0		0	0		0
H1036	341	0	1	01	01	H1036_341_0	3		N	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	25		25				25		25	25		25	25		25
H1036	341	0	1	01	01	H1036_341_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1036	341	0	1	01	01	H1036_341_0	3		N	Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1045	001	0	1	01	01	H1045_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	001	0	1	01	01	H1045_001_0	4			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	4			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	25		25						25				25		25
H1045	001	0	1	01	01	H1045_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				84.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	001	0	1	01	01	H1045_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				666.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	005	0	1	01	01	H1045_005_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	005	0	1	01	01	H1045_005_0	4			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	005	0	1	01	01	H1045_005_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				39.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H1045	005	0	1	01	01	H1045_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				100.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	005	0	1	01	01	H1045_005_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				411.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	012	0	1	01	01	H1045_012_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	012	0	1	01	01	H1045_012_0	4		N	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																														
H1045	012	0	1	01	01	H1045_012_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H1045	012	0	1	01	01	H1045_012_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	012	0	1	01	01	H1045_012_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				403.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	018	0	1	01	01	H1045_018_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	018	0	1	01	01	H1045_018_0	4			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	4			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	25		25						25				25		25
H1045	018	0	1	01	01	H1045_018_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				80.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	018	0	1	01	01	H1045_018_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				651.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	025	0	1	02	01	H1045_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	025	0	1	02	01	H1045_025_0	4			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	025	0	1	02	01	H1045_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1045	025	0	1	02	01	H1045_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				97.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	025	0	1	02	01	H1045_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				447.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	026	0	1	02	01	H1045_026_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	026	0	1	02	01	H1045_026_0	4			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	026	0	1	02	01	H1045_026_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	026	0	1	02	01	H1045_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				87.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	026	0	1	02	01	H1045_026_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				402.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	028	0	1	02	01	H1045_028_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	028	0	1	02	01	H1045_028_0	4			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	028	0	1	02	01	H1045_028_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	028	0	1	02	01	H1045_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				84.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	028	0	1	02	01	H1045_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				436.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	030	0	1	02	01	H1045_030_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	030	0	1	02	01	H1045_030_0	4			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	030	0	1	02	01	H1045_030_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	030	0	1	02	01	H1045_030_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				96.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	030	0	1	02	01	H1045_030_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				433.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	031	0	1	02	01	H1045_031_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	031	0	1	02	01	H1045_031_0	4			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	031	0	1	02	01	H1045_031_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	23		23						23				23		23
H1045	031	0	1	02	01	H1045_031_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	031	0	1	02	01	H1045_031_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				390.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	033	0	1	02	01	H1045_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	033	0	1	02	01	H1045_033_0	4			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	033	0	1	02	01	H1045_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1045	033	0	1	02	01	H1045_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				74.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	033	0	1	02	01	H1045_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				351.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	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	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	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1045	034	0	1	02	01	H1045_034_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				97.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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				421.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	036	0	1	02	01	H1045_036_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	036	0	1	02	01	H1045_036_0	4			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	036	0	1	02	01	H1045_036_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	036	0	1	02	01	H1045_036_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				93.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	036	0	1	02	01	H1045_036_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				459.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	037	0	1	01	01	H1045_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	037	0	1	01	01	H1045_037_0	4			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	037	0	1	01	01	H1045_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H1045	037	0	1	01	01	H1045_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				91.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	037	0	1	01	01	H1045_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				420.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	038	0	1	01	01	H1045_038_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	038	0	1	01	01	H1045_038_0	4		N	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																														
H1045	038	0	1	01	01	H1045_038_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H1045	038	0	1	01	01	H1045_038_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	038	0	1	01	01	H1045_038_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				402.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	039	0	1	02	01	H1045_039_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	039	0	1	02	01	H1045_039_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	039	0	1	02	01	H1045_039_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H1045	039	0	1	02	01	H1045_039_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	039	0	1	02	01	H1045_039_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	041	0	1	02	01	H1045_041_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	041	0	1	02	01	H1045_041_0	4			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	041	0	1	02	01	H1045_041_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	23		23						23				23		23
H1045	041	0	1	02	01	H1045_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				76.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	041	0	1	02	01	H1045_041_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	042	0	1	02	01	H1045_042_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	042	0	1	02	01	H1045_042_0	4			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	042	0	1	02	01	H1045_042_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				62.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	23		23						23				23		23
H1045	042	0	1	02	01	H1045_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				89.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	042	0	1	02	01	H1045_042_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				436.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	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	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	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	043	0	1	02	01	H1045_043_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				94.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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				382.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	045	0	1	02	01	H1045_045_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	045	0	1	02	01	H1045_045_0	4			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	045	0	1	02	01	H1045_045_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H1045	045	0	1	02	01	H1045_045_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				87.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	045	0	1	02	01	H1045_045_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				439.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	1	1	02	01	H1045_048_1	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	048	1	1	02	01	H1045_048_1	4			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	048	1	1	02	01	H1045_048_1	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				70.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	25		25						25				25		25
H1045	048	1	1	02	01	H1045_048_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				67.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	1	1	02	01	H1045_048_1	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	2	1	02	01	H1045_048_2	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	048	2	1	02	01	H1045_048_2	4			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	048	2	1	02	01	H1045_048_2	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				70.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	25		25						25				25		25
H1045	048	2	1	02	01	H1045_048_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				67.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	2	1	02	01	H1045_048_2	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	3	1	02	01	H1045_048_3	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	048	3	1	02	01	H1045_048_3	4			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	048	3	1	02	01	H1045_048_3	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				70.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	25		25						25				25		25
H1045	048	3	1	02	01	H1045_048_3	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				67.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	3	1	02	01	H1045_048_3	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	4	1	02	01	H1045_048_4	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	048	4	1	02	01	H1045_048_4	4			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	048	4	1	02	01	H1045_048_4	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				70.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	25		25						25				25		25
H1045	048	4	1	02	01	H1045_048_4	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				67.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	048	4	1	02	01	H1045_048_4	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	055	0	1	02	01	H1045_055_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	055	0	1	02	01	H1045_055_0	4			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	055	0	1	02	01	H1045_055_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				44.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H1045	055	0	1	02	01	H1045_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				84.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	055	0	1	02	01	H1045_055_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	056	0	1	02	01	H1045_056_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	056	0	1	02	01	H1045_056_0	4			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	056	0	1	02	01	H1045_056_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1045	056	0	1	02	01	H1045_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				95.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	056	0	1	02	01	H1045_056_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				438.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	057	0	1	02	01	H1045_057_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	057	0	1	02	01	H1045_057_0	4			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	057	0	1	02	01	H1045_057_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H1045	057	0	1	02	01	H1045_057_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				100.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	057	0	1	02	01	H1045_057_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				390.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	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	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	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H1045	058	0	1	02	01	H1045_058_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				100.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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				390.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	059	0	1	02	01	H1045_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	059	0	1	02	01	H1045_059_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	059	0	1	02	01	H1045_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1045	059	0	1	02	01	H1045_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1045	059	0	1	02	01	H1045_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H1045	060	0	1	02	01	H1045_060_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	060	0	1	02	01	H1045_060_0	4			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	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1045	060	0	1	02	01	H1045_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1045	060	0	1	02	01	H1045_060_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	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	25						25			25			25		25
H1045	061	0	1	01	01	H1045_061_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	061	0	1	01	01	H1045_061_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	061	0	1	01	01	H1045_061_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H1045	061	0	1	01	01	H1045_061_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H1045	061	0	1	01	01	H1045_061_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	063	0	1	02	01	H1045_063_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	063	0	1	02	01	H1045_063_0	4		N	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																														
H1045	063	0	1	02	01	H1045_063_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H1045	063	0	1	02	01	H1045_063_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	063	0	1	02	01	H1045_063_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				406.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	064	0	1	01	01	H1045_064_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	064	0	1	01	01	H1045_064_0	4		N	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																														
H1045	064	0	1	01	01	H1045_064_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H1045	064	0	1	01	01	H1045_064_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	064	0	1	01	01	H1045_064_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	065	0	1	02	01	H1045_065_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	065	0	1	02	01	H1045_065_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	065	0	1	02	01	H1045_065_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H1045	065	0	1	02	01	H1045_065_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1045	065	0	1	02	01	H1045_065_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				407.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H1045	067	0	1	02	01	H1045_067_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				354.00	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	25						25			25			25		25
H1045	069	0	1	02	01	H1045_069_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	069	0	1	02	01	H1045_069_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1045	069	0	1	02	01	H1045_069_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1045	069	0	1	02	01	H1045_069_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				98.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1045	069	0	1	02	01	H1045_069_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				384.00	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	25						25			25			25		25
H1099	001	0	1	02	01	H1099_001_0	7			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	100	1	2			100				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	001	0	1	02	01	H1099_001_0	7			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	7			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					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	25	25	25	25	25	25			25				25		25
H1099	001	0	1	02	01	H1099_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	001	0	1	02	01	H1099_001_0	7			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	25			25									25		25
H1099	006	0	1	01	01	H1099_006_0	7			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	100	1	2			100				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	006	0	1	01	01	H1099_006_0	7			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	7			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					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	25	25	25	25	25	25			25				25		25
H1099	006	0	1	01	01	H1099_006_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	006	0	1	01	01	H1099_006_0	7			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	25			25									25		25
H1099	014	0	1	01	01	H1099_014_0	8			Preferred Generic	4	11	1	2	1	1		111	01	100		1				30	60	100	1	2			100				30		31								0.00	0.00	0.00					0.00	0.00	0.00							0.00																0.00				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	014	0	1	01	01	H1099_014_0	8			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	8			Preferred Brand	4	11	1	2	3	1		111	01	100		1				30	60	100	1	2			100				30		31								47.00	94.00	141.00					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	25	25	25	25	25	25			25				25		25
H1099	014	0	1	01	01	H1099_014_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	014	0	1	01	01	H1099_014_0	8			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	25			25									25		25
H1099	016	0	1	01	01	H1099_016_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	016	0	1	01	01	H1099_016_0	7			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	7			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					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	25	25	25	25	25	25			25				25		25
H1099	016	0	1	01	01	H1099_016_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	016	0	1	01	01	H1099_016_0	7			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	25			25									25		25
H1099	023	0	1	01	01	H1099_023_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	023	0	1	01	01	H1099_023_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					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	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	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	25	25	25	25	25	25			25				25		25
H1099	023	0	1	01	01	H1099_023_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	023	0	1	01	01	H1099_023_0	6			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	25			25									25		25
H1099	024	0	1	01	01	H1099_024_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	024	0	1	01	01	H1099_024_0	6			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	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	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	25	25	25	25	25	25			25				25		25
H1099	024	0	1	01	01	H1099_024_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	024	0	1	01	01	H1099_024_0	6			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	25			25									25		25
H1099	025	0	1	02	01	H1099_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	025	0	1	02	01	H1099_025_0	6			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	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	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	25	25	25	25	25	25			25				25		25
H1099	025	0	1	02	01	H1099_025_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	025	0	1	02	01	H1099_025_0	6			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	25			25									25		25
H1099	026	0	1	01	01	H1099_026_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	026	0	1	01	01	H1099_026_0	7			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				30		31								10.00	20.00	30.00					5.00	10.00	15.00							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	7			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					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	25	25	25	25	25	25			25				25		25
H1099	026	0	1	01	01	H1099_026_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	026	0	1	01	01	H1099_026_0	7			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	25			25									25		25
H1099	027	0	1	02	01	H1099_027_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	027	0	1	02	01	H1099_027_0	6			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				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	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	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	25	25	25	25	25	25			25				25		25
H1099	027	0	1	02	01	H1099_027_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	027	0	1	02	01	H1099_027_0	6			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	25			25									25		25
H1099	028	0	1	01	01	H1099_028_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				0.00			0.00	0.00				0.00	Preferred Generic, 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	0	0	0	0	0			0				0		0
H1099	028	0	1	01	01	H1099_028_0	5			Generic	4	11	1	2	2	1		111	01	100		1				30	60	100	1	2			100				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	028	0	1	01	01	H1099_028_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					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	25	25	25	25	25	25			25				25		25
H1099	028	0	1	01	01	H1099_028_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	1	2			100				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	25	25	25	25	25	25			25				25		25
H1099	028	0	1	01	01	H1099_028_0	5			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	25			25									25		25
H1109	005	0	1	01	01	H1109_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																														
H1109	005	0	1	01	01	H1109_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																														
H1109	005	0	1	01	01	H1109_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											73.87	24	24	24				97.57	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1109	005	0	1	01	01	H1109_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											41.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1109	005	0	1	01	01	H1109_005_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											562.31	25						726.55	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	25			25			25			25			25		25
H1112	006	0	1	02	01	H1112_006_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	006	0	1	02	01	H1112_006_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	006	0	1	02	01	H1112_006_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											80.12	20	20	20				80.12	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1112	006	0	1	02	01	H1112_006_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	006	0	1	02	01	H1112_006_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	006	0	1	02	01	H1112_006_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	033	0	1	02	01	H1112_033_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					1.00	2.00	3.00												38.00	57.00					2.00	0.00				19.00				19.00			0.63	0.03				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	033	0	1	02	01	H1112_033_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	033	0	1	02	01	H1112_033_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.41	20	20	20				83.41	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1112	033	0	1	02	01	H1112_033_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	033	0	1	02	01	H1112_033_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	033	0	1	02	01	H1112_033_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	038	0	1	02	01	H1112_038_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1112	038	0	1	02	01	H1112_038_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1112	038	0	1	02	01	H1112_038_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											118.38	25	25	25				118.38	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	038	0	1	02	01	H1112_038_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.59	40	40	40				91.59	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	038	0	1	02	01	H1112_038_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	038	0	1	02	01	H1112_038_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1112	039	0	1	02	01	H1112_039_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1112	039	0	1	02	01	H1112_039_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.34	25	25	25				123.34	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	039	0	1	02	01	H1112_039_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.56	43	43	43				65.99	42	42	42											43	43					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	039	0	1	02	01	H1112_039_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	039	0	1	02	01	H1112_039_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1112	042	0	1	02	01	H1112_042_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1112	042	0	1	02	01	H1112_042_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.22	25	25	25				116.22	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	042	0	1	02	01	H1112_042_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.28	50	50	50				74.28	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	042	0	1	02	01	H1112_042_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	042	0	1	02	01	H1112_042_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	043	0	1	02	01	H1112_043_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.81	20	20	20				82.81	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1112	043	0	1	02	01	H1112_043_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											52.56	40	40	40				47.30	36	36	36											40	40					36	36			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	043	0	1	02	01	H1112_043_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1112	044	0	1	02	01	H1112_044_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1112	044	0	1	02	01	H1112_044_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.20	25	25	25				130.20	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	044	0	1	02	01	H1112_044_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											55.29	36	36	36				53.76	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	044	0	1	02	01	H1112_044_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	044	0	1	02	01	H1112_044_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	046	0	1	02	01	H1112_046_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	046	0	1	02	01	H1112_046_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	046	0	1	02	01	H1112_046_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.23	21	21	21				86.23	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H1112	046	0	1	02	01	H1112_046_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	046	0	1	02	01	H1112_046_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	046	0	1	02	01	H1112_046_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	047	0	1	02	01	H1112_047_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	047	0	1	02	01	H1112_047_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	047	0	1	02	01	H1112_047_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.93	20	20	20				78.93	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1112	047	0	1	02	01	H1112_047_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	047	0	1	02	01	H1112_047_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	047	0	1	02	01	H1112_047_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	048	0	1	02	01	H1112_048_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	048	0	1	02	01	H1112_048_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	048	0	1	02	01	H1112_048_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.93	20	20	20				78.93	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1112	048	0	1	02	01	H1112_048_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	048	0	1	02	01	H1112_048_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	048	0	1	02	01	H1112_048_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	049	0	1	02	01	H1112_049_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1112	049	0	1	02	01	H1112_049_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1112	049	0	1	02	01	H1112_049_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.95	25	25	25				120.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	049	0	1	02	01	H1112_049_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											60.17	37	37	37				58.54	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1112	049	0	1	02	01	H1112_049_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1112	049	0	1	02	01	H1112_049_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			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	0	0	0				0	0	0				0		0
H1170	002	0	1	01	01	H1170_002_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	002	0	1	01	01	H1170_002_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	47.00	94.00	141.00																			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, Vaccines	35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	002	0	1	01	01	H1170_002_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	002	0	1	01	01	H1170_002_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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	002	0	1	01	01	H1170_002_0	6			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	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	008	0	1	01	01	H1170_008_0	6		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	0	0	0				0	0	0				0		0
H1170	008	0	1	01	01	H1170_008_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				26.00	10	10	10																		10	10	10															10			10								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	0	0	0				0	0	0				0		0
H1170	008	0	1	01	01	H1170_008_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				59.00	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	0	0	0				0	0	0				0		0
H1170	008	0	1	01	01	H1170_008_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	008	0	1	01	01	H1170_008_0	6		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	6			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	0	0	0				0	0	0				0		0
H1170	009	0	1	01	01	H1170_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	009	0	1	01	01	H1170_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	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, Vaccines	35.00	70.00	105.00				35.00	70.00	94.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	009	0	1	01	01	H1170_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	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	009	0	1	01	01	H1170_009_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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	009	0	1	01	01	H1170_009_0	6			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	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	011	0	1	01	01	H1170_011_0	6		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	0	0	0				0	0	0				0		0
H1170	011	0	1	01	01	H1170_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		31				44.00	17	17	17																		17	17	17															17			17								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	0	0	0				0	0	0				0		0
H1170	011	0	1	01	01	H1170_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		31				67.00	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	0	0	0				0	0	0				0		0
H1170	011	0	1	01	01	H1170_011_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	011	0	1	01	01	H1170_011_0	6		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	6			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	0	0	0				0	0	0				0		0
H1170	012	0	1	01	01	H1170_012_0	6			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	25	25	25				25	0	0				25		25
H1170	012	0	1	01	01	H1170_012_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H1170	012	0	1	01	01	H1170_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	012	0	1	01	01	H1170_012_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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	012	0	1	01	01	H1170_012_0	6			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	6			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	0	0	0				0	0	0				0		0
H1170	013	0	1	02	01	H1170_013_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	013	0	1	02	01	H1170_013_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H1170	013	0	1	02	01	H1170_013_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	013	0	1	02	01	H1170_013_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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	013	0	1	02	01	H1170_013_0	6			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	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	015	0	1	01	01	H1170_015_0	6		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	0	0	0				0	0	0				0		0
H1170	015	0	1	01	01	H1170_015_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				48.00	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	0	0	0				0	0	0				0		0
H1170	015	0	1	01	01	H1170_015_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				69.00	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	0	0	0				0	0	0				0		0
H1170	015	0	1	01	01	H1170_015_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	015	0	1	01	01	H1170_015_0	6		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	016	0	1	01	01	H1170_016_0	6			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	0	0	0				0	0	0				0		0
H1170	016	0	1	01	01	H1170_016_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1170	016	0	1	01	01	H1170_016_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	94.00																47.00				47.00		1.57			1.57			1.52	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	25	25	25				25	25	25				25		25
H1170	016	0	1	01	01	H1170_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	190.00																95.00				95.00		3.17			3.17			3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	016	0	1	01	01	H1170_016_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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1170	016	0	1	01	01	H1170_016_0	6			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	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	5.00	10.00	15.00																					10.00																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	5			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				106.96	25	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	25	25	25						25				25		25
H1189	002	0	1	01	01	H1189_002_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				81.14	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	25	25	25						25				25		25
H1189	002	0	1	01	01	H1189_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				570.94	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	002	0	1	01	01	H1189_002_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	5.00	10.00	15.00																					10.00																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	5			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				117.83	25	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	25	25	25						25				25		25
H1189	003	0	1	01	01	H1189_003_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				87.12	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	25	25	25						25				25		25
H1189	003	0	1	01	01	H1189_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				546.77	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	003	0	1	01	01	H1189_003_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	5.00	10.00	15.00																					10.00																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	5			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				118.03	25	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	25	25	25						25				25		25
H1189	004	0	1	01	01	H1189_004_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				81.15	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	25	25	25						25				25		25
H1189	004	0	1	01	01	H1189_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				558.91	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	004	0	1	01	01	H1189_004_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					10.00																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	7			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				113.77	25	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	25	25	25						25				25		25
H1189	005	0	1	01	01	H1189_005_0	7			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				82.25	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	25	25	25						25				25		25
H1189	005	0	1	01	01	H1189_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				567.79	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	005	0	1	01	01	H1189_005_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					10.00																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	5			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				123.21	25	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	25	25	25						25				25		25
H1189	009	0	1	01	01	H1189_009_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				87.76	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	25	25	25						25				25		25
H1189	009	0	1	01	01	H1189_009_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				637.90	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	009	0	1	01	01	H1189_009_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		34	5.00	10.00	15.00																					10.00																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	5			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		34				109.71	25	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	25	25	25						25				25		25
H1189	010	0	1	01	01	H1189_010_0	5			Non-Preferred Drug	4	10	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		34				81.75	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	25	25	25						25				25		25
H1189	010	0	1	01	01	H1189_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				531.59	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1189	010	0	1	01	01	H1189_010_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		34	0.00	0.00	0.00																					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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.28	24	24	24				91.86	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1206	002	0	1	02	01	H1206_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											39.44	25	25	25				43.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1206	002	0	1	02	01	H1206_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											541.35	25						707.54	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	25			25			25			25			25		25
H1206	003	0	1	02	01	H1206_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																														
H1206	003	0	1	02	01	H1206_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																														
H1206	003	0	1	02	01	H1206_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											66.59	24	24	24				91.51	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1206	003	0	1	02	01	H1206_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											40.89	25	25	25				49.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1206	003	0	1	02	01	H1206_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											558.37	25						660.25	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	004	0	1	01	01	H1206_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											67.06	25	25	25				84.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											41.03	30	30	30				48.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											553.10	30						836.57	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	25			25			25			25			25		25
H1206	008	0	1	02	01	H1206_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																														
H1206	008	0	1	02	01	H1206_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																														
H1206	008	0	1	02	01	H1206_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											65.30	24	24	24				90.32	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1206	008	0	1	02	01	H1206_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											39.97	25	25	25				48.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1206	008	0	1	02	01	H1206_008_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											547.69	25						655.62	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	25			25			25			25			25		25
H1206	009	0	1	01	01	H1206_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1206	009	0	1	01	01	H1206_009_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H1206	009	0	1	01	01	H1206_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				86.64	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1206	009	0	1	01	01	H1206_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				37.27	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1206	009	0	1	01	01	H1206_009_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				509.54	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1212	001	0	1	01	01	H1212_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H1212	001	0	1	01	01	H1212_001_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1212	001	0	1	01	01	H1212_001_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1212	001	0	1	01	01	H1212_001_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				27.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1212	001	0	1	01	01	H1212_001_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																														
H1212	001	0	1	01	01	H1212_001_0	6		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																														
H1212	002	0	1	01	01	H1212_002_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H1212	002	0	1	01	01	H1212_002_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1212	002	0	1	01	01	H1212_002_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				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1212	002	0	1	01	01	H1212_002_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				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1212	002	0	1	01	01	H1212_002_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, Select Care Drugs																														
H1212	002	0	1	01	01	H1212_002_0	7		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																														
H1212	003	0	1	02	01	H1212_003_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								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																														
H1212	003	0	1	02	01	H1212_003_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1212	003	0	1	02	01	H1212_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.00	25	25	25				94.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H1212	003	0	1	02	01	H1212_003_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											18.00	30	30	30				13.00	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	25	25	25	25	25	25	25	25	25				25		25
H1212	003	0	1	02	01	H1212_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1215	001	0	1	02	01	H1215_001_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00												38.00	57.00					0.00	0.00				19.00				19.00			0.63	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1215	001	0	1	02	01	H1215_001_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					5.00	10.00	15.00												40.00	60.00					10.00	0.00				20.00				20.00			0.67	0.17				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1215	001	0	1	02	01	H1215_001_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											84.69	20	20	20				84.69	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1215	001	0	1	02	01	H1215_001_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1215	001	0	1	02	01	H1215_001_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1215	003	0	1	02	01	H1215_003_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1215	003	0	1	02	01	H1215_003_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.30	25	25	25				123.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1215	003	0	1	02	01	H1215_003_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.22	38	38	38				70.32	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1215	003	0	1	02	01	H1215_003_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1215	003	0	1	02	01	H1215_003_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1215	005	0	1	02	01	H1215_005_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1215	005	0	1	02	01	H1215_005_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1215	005	0	1	02	01	H1215_005_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.90	25	25	25				119.90	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1215	005	0	1	02	01	H1215_005_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											58.68	37	37	37				57.10	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1215	005	0	1	02	01	H1215_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1215	005	0	1	02	01	H1215_005_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1224	001	0	1	01	01	H1224_001_0	4		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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1224	001	0	1	01	01	H1224_001_0	4		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				9.41	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1224	001	0	1	01	01	H1224_001_0	4		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				82.31	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	25	25	25				25	25	25				25		25
H1224	001	0	1	01	01	H1224_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				124.26	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1224	001	0	1	01	01	H1224_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				577.02	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1225	001	0	1	01	01	H1225_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	0	0	0				0	0	0				0		0
H1225	001	0	1	01	01	H1225_001_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	9.00	12.00																			6.00	9.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	9.00	12.00				6.00	9.00	12.00				6.00		6.00	25	25	25				25	25	25				25		25
H1225	001	0	1	01	01	H1225_001_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	67.50	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	52.50	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1225	001	0	1	01	01	H1225_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				74.16	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1225	001	0	1	01	01	H1225_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				800.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1230	001	0	1	01	01	H1230_001_0	3			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																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	4.00	8.00	12.00				0.00	0.00	0.00				4.00		4.00	25	25	25				0	0	0				25		25
H1230	001	0	1	01	01	H1230_001_0	3			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	25	25	25				25	25	25				25		25
H1230	001	0	1	01	01	H1230_001_0	3			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	43.00	86.00	129.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	86.00				35.00		35.00	25	25	25				25	25	25				25		25
H1230	001	0	1	01	01	H1230_001_0	3			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	25	25	25				25	25	25				25		25
H1230	001	0	1	01	01	H1230_001_0	3			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	25	25	25				25	25	25				25		25
H1230	001	0	1	01	01	H1230_001_0	3			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	3			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																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	4.00	8.00	12.00				0.00	0.00	0.00				4.00		4.00	25	25	25				0	0	0				25		25
H1230	003	0	1	01	01	H1230_003_0	3			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	25	25	25				25	25	25				25		25
H1230	003	0	1	01	01	H1230_003_0	3			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	43.00	86.00	129.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	86.00				35.00		35.00	25	25	25				25	25	25				25		25
H1230	003	0	1	01	01	H1230_003_0	3			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	25	25	25				25	25	25				25		25
H1230	003	0	1	01	01	H1230_003_0	3			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								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	25	25	25				25	25	25				25		25
H1230	003	0	1	01	01	H1230_003_0	3			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	3			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																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	4.00	8.00	12.00				0.00	0.00	0.00				4.00		4.00	25	25	25				0	0	0				25		25
H1230	013	0	1	01	01	H1230_013_0	3			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	25	25	25				25	25	25				25		25
H1230	013	0	1	01	01	H1230_013_0	3			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	43.00	86.00	129.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	86.00				35.00		35.00	25	25	25				25	25	25				25		25
H1230	013	0	1	01	01	H1230_013_0	3			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	25	25	25				25	25	25				25		25
H1230	013	0	1	01	01	H1230_013_0	3			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								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	25	25	25				25	25	25				25		25
H1230	013	0	1	01	01	H1230_013_0	3			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	3			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																4.00				4.00		0.13			0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	4.00	8.00	12.00				0.00	0.00	0.00				4.00		4.00	25	25	25				0	0	0				25		25
H1230	014	0	1	01	01	H1230_014_0	3			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	25	25	25				25	25	25				25		25
H1230	014	0	1	01	01	H1230_014_0	3			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	43.00	86.00	129.00																			43.00	86.00	86.00																43.00				43.00		1.43			1.43			1.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00				35.00	70.00	86.00				35.00		35.00	25	25	25				25	25	25				25		25
H1230	014	0	1	01	01	H1230_014_0	3			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	25	25	25				25	25	25				25		25
H1230	014	0	1	01	01	H1230_014_0	3			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								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	25	25	25				25	25	25				25		25
H1230	014	0	1	01	01	H1230_014_0	3			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	13			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	13			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	004	0	1	04	01	H1248_004_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											75.93	50	50	50				60.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	004	0	1	04	01	H1248_004_0	13			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1332.21	29						864.45	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1248	007	0	1	04	01	H1248_007_0	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	007	0	1	04	01	H1248_007_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											79.82	50	50	50				53.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	007	0	1	04	01	H1248_007_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											877.27	29						1039.85	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1248	014	0	1	04	01	H1248_014_0	12			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	014	0	1	04	01	H1248_014_0	12			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	014	0	1	04	01	H1248_014_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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	014	0	1	04	01	H1248_014_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											70.91	50	50	50				54.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1248	014	0	1	04	01	H1248_014_0	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1085.45	29						847.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	003	0	1	04	01	H1278_003_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	003	0	1	04	01	H1278_003_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	003	0	1	04	01	H1278_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	003	0	1	04	01	H1278_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	003	0	1	04	01	H1278_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	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	25						25			25			25		25
H1278	005	0	1	04	01	H1278_005_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	005	0	1	04	01	H1278_005_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	005	0	1	04	01	H1278_005_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	005	0	1	04	01	H1278_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	005	0	1	04	01	H1278_005_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H1278	010	0	1	04	01	H1278_010_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	010	0	1	04	01	H1278_010_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	010	0	1	04	01	H1278_010_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	010	0	1	04	01	H1278_010_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	010	0	1	04	01	H1278_010_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H1278	013	0	1	04	01	H1278_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	013	0	1	04	01	H1278_013_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	013	0	1	04	01	H1278_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	013	0	1	04	01	H1278_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	013	0	1	04	01	H1278_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				353.00	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	25						25			25			25		25
H1278	014	0	1	04	01	H1278_014_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	014	0	1	04	01	H1278_014_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	014	0	1	04	01	H1278_014_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	014	0	1	04	01	H1278_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	014	0	1	04	01	H1278_014_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H1278	015	0	1	04	01	H1278_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	015	0	1	04	01	H1278_015_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	015	0	1	04	01	H1278_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1278	015	0	1	04	01	H1278_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	015	0	1	04	01	H1278_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H1278	016	0	1	04	01	H1278_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	016	0	1	04	01	H1278_016_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	016	0	1	04	01	H1278_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H1278	016	0	1	04	01	H1278_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	016	0	1	04	01	H1278_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				331.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	020	0	1	04	01	H1278_020_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	020	0	1	04	01	H1278_020_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	020	0	1	04	01	H1278_020_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H1278	020	0	1	04	01	H1278_020_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	020	0	1	04	01	H1278_020_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				339.00	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	25						25			25			25		25
H1278	021	0	1	04	01	H1278_021_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	021	0	1	04	01	H1278_021_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	021	0	1	04	01	H1278_021_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	021	0	1	04	01	H1278_021_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	021	0	1	04	01	H1278_021_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				347.00	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	25						25			25			25		25
H1278	024	0	1	04	01	H1278_024_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	024	0	1	04	01	H1278_024_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	024	0	1	04	01	H1278_024_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1278	024	0	1	04	01	H1278_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	024	0	1	04	01	H1278_024_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				394.00	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	25						25			25			25		25
H1278	028	0	1	04	01	H1278_028_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	028	0	1	04	01	H1278_028_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	028	0	1	04	01	H1278_028_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	028	0	1	04	01	H1278_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	028	0	1	04	01	H1278_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H1278	029	0	1	04	01	H1278_029_0	3			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3			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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	029	0	1	04	01	H1278_029_0	3			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				31.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	029	0	1	04	01	H1278_029_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	029	0	1	04	01	H1278_029_0	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H1278	030	0	1	04	01	H1278_030_0	3			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	030	0	1	04	01	H1278_030_0	3			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	030	0	1	04	01	H1278_030_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	030	0	1	04	01	H1278_030_0	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H1278	032	0	1	04	01	H1278_032_0	3			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1278	032	0	1	04	01	H1278_032_0	3			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1278	032	0	1	04	01	H1278_032_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1278	032	0	1	04	01	H1278_032_0	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H1280	001	0	1	01	01	H1280_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1280	001	0	1	01	01	H1280_001_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H1280	001	0	1	01	01	H1280_001_0	4			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				64.40	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	70.00				35.00		35.00	23	23	23				23	23	23				23		23
H1280	001	0	1	01	01	H1280_001_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				79.58	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H1280	001	0	1	01	01	H1280_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				616.99	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1285	001	0	1	01	01	H1285_001_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H1285	001	0	1	01	01	H1285_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1285	001	0	1	01	01	H1285_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1285	001	0	1	01	01	H1285_001_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H1285	001	0	1	01	01	H1285_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				360.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1285	002	0	1	02	01	H1285_002_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H1285	002	0	1	02	01	H1285_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1285	002	0	1	02	01	H1285_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H1285	002	0	1	02	01	H1285_002_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H1285	002	0	1	02	01	H1285_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				337.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				83.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				115.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	002	0	1	01	01	H1290_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	0	0	0				0	0	0				0		0
H1290	002	0	1	01	01	H1290_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	0	0	0				0	0	0				0		0
H1290	002	0	1	01	01	H1290_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	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	002	0	1	01	01	H1290_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				104.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	002	0	1	01	01	H1290_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	25						25						25		25
H1290	003	0	1	01	01	H1290_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	0	0	0				0	0	0				0		0
H1290	003	0	1	01	01	H1290_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	0	0	0				0	0	0				0		0
H1290	003	0	1	01	01	H1290_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				85.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	003	0	1	01	01	H1290_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				108.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	003	0	1	01	01	H1290_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	013	0	1	01	01	H1290_013_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H1290	013	0	1	01	01	H1290_013_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																			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	25	25	25				25	25	25				25		25
H1290	013	0	1	01	01	H1290_013_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				93.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	013	0	1	01	01	H1290_013_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				129.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	013	0	1	01	01	H1290_013_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	25						25						25		25
H1290	014	0	1	01	01	H1290_014_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	0	0	0				0	0	0				0		0
H1290	014	0	1	01	01	H1290_014_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																			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	25	25	25				25	25	25				25		25
H1290	014	0	1	01	01	H1290_014_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				94.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	014	0	1	01	01	H1290_014_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				127.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	014	0	1	01	01	H1290_014_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	25						25						25		25
H1290	015	0	1	01	01	H1290_015_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	0	0	0				0	0	0				0		0
H1290	015	0	1	01	01	H1290_015_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																			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	25	25	25				25	25	25				25		25
H1290	015	0	1	01	01	H1290_015_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				90.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	015	0	1	01	01	H1290_015_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				133.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	015	0	1	01	01	H1290_015_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	25						25						25		25
H1290	018	0	1	01	01	H1290_018_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	0	0	0				0	0	0				0		0
H1290	018	0	1	01	01	H1290_018_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																			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	25	25	25				25	25	25				25		25
H1290	018	0	1	01	01	H1290_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				89.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	018	0	1	01	01	H1290_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				127.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	018	0	1	01	01	H1290_018_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	25						25						25		25
H1290	019	0	1	01	01	H1290_019_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	019	0	1	01	01	H1290_019_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	019	0	1	01	01	H1290_019_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	019	0	1	01	01	H1290_019_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				88.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	019	0	1	01	01	H1290_019_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	019	0	1	01	01	H1290_019_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	020	0	1	01	01	H1290_020_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	020	0	1	01	01	H1290_020_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	020	0	1	01	01	H1290_020_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				57.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	020	0	1	01	01	H1290_020_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				78.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	020	0	1	01	01	H1290_020_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	020	0	1	01	01	H1290_020_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	021	0	1	01	01	H1290_021_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	021	0	1	01	01	H1290_021_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	021	0	1	01	01	H1290_021_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	021	0	1	01	01	H1290_021_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				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	021	0	1	01	01	H1290_021_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	021	0	1	01	01	H1290_021_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	022	0	1	01	01	H1290_022_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	022	0	1	01	01	H1290_022_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	022	0	1	01	01	H1290_022_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				55.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	022	0	1	01	01	H1290_022_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	022	0	1	01	01	H1290_022_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	022	0	1	01	01	H1290_022_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	023	0	1	01	01	H1290_023_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	023	0	1	01	01	H1290_023_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	023	0	1	01	01	H1290_023_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				55.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	023	0	1	01	01	H1290_023_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	023	0	1	01	01	H1290_023_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	023	0	1	01	01	H1290_023_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	024	0	1	01	01	H1290_024_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	024	0	1	01	01	H1290_024_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	024	0	1	01	01	H1290_024_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	024	0	1	01	01	H1290_024_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	024	0	1	01	01	H1290_024_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	024	0	1	01	01	H1290_024_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	025	0	1	01	01	H1290_025_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	0	0	0				0	0	0				0		0
H1290	025	0	1	01	01	H1290_025_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	0	0	0				0	0	0				0		0
H1290	025	0	1	01	01	H1290_025_0	8			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	25	25	25				25	25	25				25		25
H1290	025	0	1	01	01	H1290_025_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				95.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	025	0	1	01	01	H1290_025_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	25						25						25		25
H1290	027	0	1	01	01	H1290_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	027	0	1	01	01	H1290_027_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	0	0	0				0	0	0				0		0
H1290	027	0	1	01	01	H1290_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				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	25	25	25				25	25	25				25		25
H1290	027	0	1	01	01	H1290_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				90.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	027	0	1	01	01	H1290_027_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	25						25						25		25
H1290	029	0	1	01	01	H1290_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	029	0	1	01	01	H1290_029_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	029	0	1	01	01	H1290_029_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	029	0	1	01	01	H1290_029_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				101.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	029	0	1	01	01	H1290_029_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	25						25						25		25
H1290	031	0	1	01	01	H1290_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	031	0	1	01	01	H1290_031_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																			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	25	25	25				25	25	25				25		25
H1290	031	0	1	01	01	H1290_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				94.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	031	0	1	01	01	H1290_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				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	25	25	25				25	25	25				25		25
H1290	031	0	1	01	01	H1290_031_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	25						25						25		25
H1290	032	0	1	01	01	H1290_032_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	032	0	1	01	01	H1290_032_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	25	25	25				25	25	25				25		25
H1290	032	0	1	01	01	H1290_032_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	032	0	1	01	01	H1290_032_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				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	25	25	25				25	25	25				25		25
H1290	032	0	1	01	01	H1290_032_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	25						25						25		25
H1290	033	0	1	01	01	H1290_033_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	033	0	1	01	01	H1290_033_0	8		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	033	0	1	01	01	H1290_033_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	033	0	1	01	01	H1290_033_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	033	0	1	01	01	H1290_033_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	033	0	1	01	01	H1290_033_0	8		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	034	0	1	01	01	H1290_034_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	034	0	1	01	01	H1290_034_0	8		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	034	0	1	01	01	H1290_034_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	034	0	1	01	01	H1290_034_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	034	0	1	01	01	H1290_034_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	034	0	1	01	01	H1290_034_0	8		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	035	0	1	01	01	H1290_035_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	0	0	0				0	0	0				0		0
H1290	035	0	1	01	01	H1290_035_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																			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	25	25	25				25	25	25				25		25
H1290	035	0	1	01	01	H1290_035_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				89.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	035	0	1	01	01	H1290_035_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				101.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	035	0	1	01	01	H1290_035_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				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	25	25	25				25	25	25				25		25
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				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				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	25	25	25				25	25	25				25		25
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				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	037	1	1	01	01	H1290_037_1	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	0	0	0				0	0	0				0		0
H1290	037	1	1	01	01	H1290_037_1	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	0	0	0				0	0	0				0		0
H1290	037	1	1	01	01	H1290_037_1	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	037	1	1	01	01	H1290_037_1	8			Non-Preferred Drug	4	11	1	1	4	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	25	25	25				25	25	25				25		25
H1290	037	1	1	01	01	H1290_037_1	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	25						25						25		25
H1290	037	2	1	01	01	H1290_037_2	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	037	2	1	01	01	H1290_037_2	11			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	037	2	1	01	01	H1290_037_2	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	037	2	1	01	01	H1290_037_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				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	25	25	25				25	25	25				25		25
H1290	037	2	1	01	01	H1290_037_2	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	25						25						25		25
H1290	037	3	1	01	01	H1290_037_3	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	0	0	0				0	0	0				0		0
H1290	037	3	1	01	01	H1290_037_3	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	0	0	0				0	0	0				0		0
H1290	037	3	1	01	01	H1290_037_3	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	037	3	1	01	01	H1290_037_3	8			Non-Preferred Drug	4	11	1	1	4	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	25	25	25				25	25	25				25		25
H1290	037	3	1	01	01	H1290_037_3	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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				84.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	037	5	1	01	01	H1290_037_5	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	0	0	0				0	0	0				0		0
H1290	037	5	1	01	01	H1290_037_5	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	0	0	0				0	0	0				0		0
H1290	037	5	1	01	01	H1290_037_5	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	037	5	1	01	01	H1290_037_5	10			Non-Preferred Drug	4	11	1	1	4	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	25	25	25				25	25	25				25		25
H1290	037	5	1	01	01	H1290_037_5	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	25						25						25		25
H1290	039	0	1	01	01	H1290_039_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	039	0	1	01	01	H1290_039_0	8		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	039	0	1	01	01	H1290_039_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	039	0	1	01	01	H1290_039_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	039	0	1	01	01	H1290_039_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	039	0	1	01	01	H1290_039_0	8		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	041	0	1	01	01	H1290_041_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	041	0	1	01	01	H1290_041_0	8		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	041	0	1	01	01	H1290_041_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	041	0	1	01	01	H1290_041_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	041	0	1	01	01	H1290_041_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	041	0	1	01	01	H1290_041_0	8		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	042	0	1	01	01	H1290_042_0	9		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	042	0	1	01	01	H1290_042_0	9		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	042	0	1	01	01	H1290_042_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	042	0	1	01	01	H1290_042_0	9		N	Non-Preferred Drug	4	11	1	1	4	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	042	0	1	01	01	H1290_042_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	042	0	1	01	01	H1290_042_0	9		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	043	0	1	01	01	H1290_043_0	9		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	043	0	1	01	01	H1290_043_0	9		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	043	0	1	01	01	H1290_043_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	043	0	1	01	01	H1290_043_0	9		N	Non-Preferred Drug	4	11	1	1	4	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	043	0	1	01	01	H1290_043_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	043	0	1	01	01	H1290_043_0	9		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	044	1	1	01	01	H1290_044_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	0	0	0				0	0	0				0		0
H1290	044	1	1	01	01	H1290_044_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	0	0	0				0	0	0				0		0
H1290	044	1	1	01	01	H1290_044_1	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				87.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	044	1	1	01	01	H1290_044_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				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	25	25	25				25	25	25				25		25
H1290	044	1	1	01	01	H1290_044_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	25						25						25		25
H1290	044	2	1	01	01	H1290_044_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	0	0	0				0	0	0				0		0
H1290	044	2	1	01	01	H1290_044_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	0	0	0				0	0	0				0		0
H1290	044	2	1	01	01	H1290_044_2	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				87.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	044	2	1	01	01	H1290_044_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				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	25	25	25				25	25	25				25		25
H1290	044	2	1	01	01	H1290_044_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	25						25						25		25
H1290	044	3	1	01	01	H1290_044_3	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	0	0	0				0	0	0				0		0
H1290	044	3	1	01	01	H1290_044_3	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	0	0	0				0	0	0				0		0
H1290	044	3	1	01	01	H1290_044_3	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				87.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	044	3	1	01	01	H1290_044_3	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				106.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	044	3	1	01	01	H1290_044_3	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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				90.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				126.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				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	25	25	25				25	25	25				25		25
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				91.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	049	0	1	01	01	H1290_049_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	0	0	0				0	0	0				0		0
H1290	049	0	1	01	01	H1290_049_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																			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	25	25	25				25	25	25				25		25
H1290	049	0	1	01	01	H1290_049_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				93.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H1290	049	0	1	01	01	H1290_049_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				133.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	049	0	1	01	01	H1290_049_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				83.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				96.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				149.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				96.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				149.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H1290	052	0	1	01	01	H1290_052_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H1290	052	0	1	01	01	H1290_052_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	052	0	1	01	01	H1290_052_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	052	0	1	01	01	H1290_052_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	052	0	1	01	01	H1290_052_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	052	0	1	01	01	H1290_052_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	053	0	1	01	01	H1290_053_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	053	0	1	01	01	H1290_053_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	053	0	1	01	01	H1290_053_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	053	0	1	01	01	H1290_053_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				77.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	053	0	1	01	01	H1290_053_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	053	0	1	01	01	H1290_053_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care 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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				57.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				1.00	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	25						25						25		25
H1290	054	0	1	01	01	H1290_054_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	055	0	1	01	01	H1290_055_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	055	0	1	01	01	H1290_055_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	055	0	1	01	01	H1290_055_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	055	0	1	01	01	H1290_055_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				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	055	0	1	01	01	H1290_055_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	055	0	1	01	01	H1290_055_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care 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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	056	0	1	01	01	H1290_056_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				20.00	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	20	20	20				20	20	20				20		20
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	058	0	1	01	01	H1290_058_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	059	0	1	01	01	H1290_059_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				32.00	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		35.00	23	23	23				23	23	23				23		23
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				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	25	25	25				25	25	25				25		25
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	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	062	0	1	01	01	H1290_062_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	063	0	1	01	01	H1290_063_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	064	0	1	01	01	H1290_064_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
H1290	065	0	1	01	01	H1290_065_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	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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				20.00	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	20	20	20				20	20	20				20		20
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				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	25	25	25				25	25	25				25		25
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	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1290	067	0	1	01	01	H1290_067_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	067	0	1	01	01	H1290_067_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	067	0	1	01	01	H1290_067_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	067	0	1	01	01	H1290_067_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	067	0	1	01	01	H1290_067_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	067	0	1	01	01	H1290_067_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	068	0	1	01	01	H1290_068_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	068	0	1	01	01	H1290_068_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	068	0	1	01	01	H1290_068_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	068	0	1	01	01	H1290_068_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	068	0	1	01	01	H1290_068_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	068	0	1	01	01	H1290_068_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	069	0	1	01	01	H1290_069_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	069	0	1	01	01	H1290_069_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	069	0	1	01	01	H1290_069_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	069	0	1	01	01	H1290_069_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	069	0	1	01	01	H1290_069_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	069	0	1	01	01	H1290_069_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	070	0	1	01	01	H1290_070_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	070	0	1	01	01	H1290_070_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	070	0	1	01	01	H1290_070_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	070	0	1	01	01	H1290_070_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	070	0	1	01	01	H1290_070_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	070	0	1	01	01	H1290_070_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	071	0	1	01	01	H1290_071_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	071	0	1	01	01	H1290_071_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	071	0	1	01	01	H1290_071_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	071	0	1	01	01	H1290_071_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	071	0	1	01	01	H1290_071_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	071	0	1	01	01	H1290_071_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	072	0	1	01	01	H1290_072_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	072	0	1	01	01	H1290_072_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	072	0	1	01	01	H1290_072_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	072	0	1	01	01	H1290_072_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	072	0	1	01	01	H1290_072_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	072	0	1	01	01	H1290_072_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	073	0	1	01	01	H1290_073_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	073	0	1	01	01	H1290_073_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	073	0	1	01	01	H1290_073_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	073	0	1	01	01	H1290_073_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	073	0	1	01	01	H1290_073_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	073	0	1	01	01	H1290_073_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	074	0	1	01	01	H1290_074_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	074	0	1	01	01	H1290_074_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H1290	074	0	1	01	01	H1290_074_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H1290	074	0	1	01	01	H1290_074_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	074	0	1	01	01	H1290_074_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	074	0	1	01	01	H1290_074_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	077	0	1	01	01	H1290_077_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	077	0	1	01	01	H1290_077_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	077	0	1	01	01	H1290_077_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	077	0	1	01	01	H1290_077_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	077	0	1	01	01	H1290_077_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	077	0	1	01	01	H1290_077_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	078	0	1	01	01	H1290_078_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	078	0	1	01	01	H1290_078_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	078	0	1	01	01	H1290_078_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	078	0	1	01	01	H1290_078_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	078	0	1	01	01	H1290_078_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	078	0	1	01	01	H1290_078_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	079	0	1	01	01	H1290_079_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	079	0	1	01	01	H1290_079_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	079	0	1	01	01	H1290_079_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	079	0	1	01	01	H1290_079_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	079	0	1	01	01	H1290_079_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	079	0	1	01	01	H1290_079_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	080	0	1	01	01	H1290_080_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	080	0	1	01	01	H1290_080_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	080	0	1	01	01	H1290_080_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	080	0	1	01	01	H1290_080_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	080	0	1	01	01	H1290_080_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	080	0	1	01	01	H1290_080_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	081	0	1	01	01	H1290_081_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	081	0	1	01	01	H1290_081_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	081	0	1	01	01	H1290_081_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	081	0	1	01	01	H1290_081_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	081	0	1	01	01	H1290_081_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	081	0	1	01	01	H1290_081_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	082	0	1	01	01	H1290_082_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	082	0	1	01	01	H1290_082_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	082	0	1	01	01	H1290_082_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	082	0	1	01	01	H1290_082_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	082	0	1	01	01	H1290_082_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	082	0	1	01	01	H1290_082_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	083	0	1	01	01	H1290_083_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H1290	083	0	1	01	01	H1290_083_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	083	0	1	01	01	H1290_083_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	083	0	1	01	01	H1290_083_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	083	0	1	01	01	H1290_083_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	083	0	1	01	01	H1290_083_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	084	0	1	01	01	H1290_084_0	9			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	084	0	1	01	01	H1290_084_0	9			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	084	0	1	01	01	H1290_084_0	9			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	084	0	1	01	01	H1290_084_0	9			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				76.00	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		35.00	25	25	25				25	25	25				25		25
H1290	084	0	1	01	01	H1290_084_0	9			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	084	0	1	01	01	H1290_084_0	9			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	085	0	1	01	01	H1290_085_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	085	0	1	01	01	H1290_085_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	085	0	1	01	01	H1290_085_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	085	0	1	01	01	H1290_085_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	085	0	1	01	01	H1290_085_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	085	0	1	01	01	H1290_085_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	086	0	1	01	01	H1290_086_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	086	0	1	01	01	H1290_086_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	086	0	1	01	01	H1290_086_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	086	0	1	01	01	H1290_086_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	086	0	1	01	01	H1290_086_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	086	0	1	01	01	H1290_086_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	087	0	1	01	01	H1290_087_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	087	0	1	01	01	H1290_087_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	087	0	1	01	01	H1290_087_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	087	0	1	01	01	H1290_087_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	087	0	1	01	01	H1290_087_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	087	0	1	01	01	H1290_087_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	088	0	1	01	01	H1290_088_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	088	0	1	01	01	H1290_088_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	088	0	1	01	01	H1290_088_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	088	0	1	01	01	H1290_088_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	088	0	1	01	01	H1290_088_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	088	0	1	01	01	H1290_088_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	089	0	1	01	01	H1290_089_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	089	0	1	01	01	H1290_089_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	089	0	1	01	01	H1290_089_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	089	0	1	01	01	H1290_089_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	089	0	1	01	01	H1290_089_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	089	0	1	01	01	H1290_089_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	090	0	1	01	01	H1290_090_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	090	0	1	01	01	H1290_090_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	090	0	1	01	01	H1290_090_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	090	0	1	01	01	H1290_090_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	090	0	1	01	01	H1290_090_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	090	0	1	01	01	H1290_090_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1290	091	0	1	01	01	H1290_091_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H1290	091	0	1	01	01	H1290_091_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H1290	091	0	1	01	01	H1290_091_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1290	091	0	1	01	01	H1290_091_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H1290	091	0	1	01	01	H1290_091_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1290	091	0	1	01	01	H1290_091_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
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	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	25		25				25		25				25		25
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	13.00		26.00																			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		26.00				13.00		26.00				13.00		13.00	25		25				25		25				25		25
H1347	001	0	1	04	01	H1347_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				40.11	19		19																		19		19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	19		19				19		19				19		19
H1347	001	0	1	04	01	H1347_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				63.64	31		31																		31		31															31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
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				487.84	29		29																		29		29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1347	002	0	1	04	01	H1347_002_0	4			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	25		25				25		25				25		25
H1347	002	0	1	04	01	H1347_002_0	4			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	13.00		26.00																			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		26.00				13.00		26.00				13.00		13.00	25		25				25		25				25		25
H1347	002	0	1	04	01	H1347_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				40.37	20		20																		20		20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	20		20				20		20				20		20
H1347	002	0	1	04	01	H1347_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				56.91	30		30																		30		30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H1347	002	0	1	04	01	H1347_002_0	4			Specialty Tier	4	10	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				644.49	29		29																		29		29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1347	003	0	1	04	01	H1347_003_0	4			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	25		25				25		25				25		25
H1347	003	0	1	04	01	H1347_003_0	4			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	13.00		26.00																			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		26.00				13.00		26.00				13.00		13.00	25		25				25		25				25		25
H1347	003	0	1	04	01	H1347_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				37.14	19		19																		19		19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	19		19				19		19				19		19
H1347	003	0	1	04	01	H1347_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				61.82	30		30																		30		30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H1347	003	0	1	04	01	H1347_003_0	4			Specialty Tier	4	10	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				648.77	29		29																		29		29															29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	032	0	1	01	01	H1350_032_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	032	0	1	01	01	H1350_032_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					6.00	12.00	18.00					6.00	12.00	18.00																6.00				6.00			0.50	0.20	0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	032	0	1	01	01	H1350_032_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	032	0	1	01	01	H1350_032_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											42.27	25	25	25				35.86	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	032	0	1	01	01	H1350_032_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											260.58	28						221.27	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	033	0	1	01	01	H1350_033_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	033	0	1	01	01	H1350_033_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					6.00	12.00	18.00					6.00	12.00	18.00																6.00				6.00			0.50	0.20	0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	033	0	1	01	01	H1350_033_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	033	0	1	01	01	H1350_033_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											42.27	25	25	25				35.86	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	033	0	1	01	01	H1350_033_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											260.58	28						221.27	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	034	0	1	01	01	H1350_034_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	034	0	1	01	01	H1350_034_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					7.00	14.00	21.00					7.00	14.00	21.00																7.00				7.00			0.50	0.23	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	034	0	1	01	01	H1350_034_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	034	0	1	01	01	H1350_034_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											40.68	25	25	25				31.45	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	034	0	1	01	01	H1350_034_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											272.20	27						218.77	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	035	0	1	01	01	H1350_035_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	035	0	1	01	01	H1350_035_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					7.00	14.00	21.00					7.00	14.00	21.00																7.00				7.00			0.50	0.23	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	035	0	1	01	01	H1350_035_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	035	0	1	01	01	H1350_035_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											38.05	25	25	25				35.33	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	035	0	1	01	01	H1350_035_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											269.20	27						236.46	27						27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	036	0	1	01	01	H1350_036_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	036	0	1	01	01	H1350_036_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					7.00	14.00	21.00					7.00	14.00	21.00																7.00				7.00			0.50	0.23	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	036	0	1	01	01	H1350_036_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	036	0	1	01	01	H1350_036_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											56.00	27	27	27				38.54	27	27	27				27	27	27															27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	036	0	1	01	01	H1350_036_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											340.59	29						292.67	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	037	0	1	01	01	H1350_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	037	0	1	01	01	H1350_037_0	8			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					7.00	14.00	21.00					7.00	14.00	21.00																7.00				7.00			0.50	0.23	0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1350	037	0	1	01	01	H1350_037_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					40.00	80.00	120.00					40.00	80.00	120.00																40.00				40.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H1350	037	0	1	01	01	H1350_037_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											46.79	25	25	25				40.02	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H1350	037	0	1	01	01	H1350_037_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											302.93	28						244.71	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1360	001	0	1	02	01	H1360_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1360	001	0	1	02	01	H1360_001_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1360	001	0	1	02	01	H1360_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1360	001	0	1	02	01	H1360_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1360	001	0	1	02	01	H1360_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1360	002	0	1	02	01	H1360_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1360	002	0	1	02	01	H1360_002_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1360	002	0	1	02	01	H1360_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H1360	002	0	1	02	01	H1360_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1360	002	0	1	02	01	H1360_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				339.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1360	003	0	1	02	01	H1360_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1360	003	0	1	02	01	H1360_003_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1360	003	0	1	02	01	H1360_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1360	003	0	1	02	01	H1360_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1360	003	0	1	02	01	H1360_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1365	001	0	1	04	01	H1365_001_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					0.00	0.00	0.00					0.00	0.00	0.00																4.00				4.00			0.13	0.00	0.00			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1365	001	0	1	04	01	H1365_001_0	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					5.00	10.00	15.00					10.00	20.00	25.00																10.00				10.00			0.33	0.17	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	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											83.14	25	25	25				86.36	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	25	25	25	25	25	25	25	25	25				25		25
H1365	001	0	1	04	01	H1365_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											76.53	32	32	32				64.97	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1365	001	0	1	04	01	H1365_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											812.53	29						580.95	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	25			25			25						25		25
H1365	001	0	1	04	01	H1365_001_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								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	005	0	1	04	01	H1365_005_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					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	005	0	1	04	01	H1365_005_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					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	005	0	1	04	01	H1365_005_0	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											76.91	25	25	25				81.72	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	25	25	25	25	25	25	25	25	25				25		25
H1365	005	0	1	04	01	H1365_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		31											77.97	32	32	32				66.64	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1365	005	0	1	04	01	H1365_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											659.59	27						608.95	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	25			25			25						25		25
H1365	005	0	1	04	01	H1365_005_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								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																														
H1372	002	0	1	01	01	H1372_002_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1372	002	0	1	01	01	H1372_002_0	7			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	15.00	30.00	45.00																			15.00	30.00	45.00																	15.00			15.00		0.50			0.50			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1372	002	0	1	01	01	H1372_002_0	7			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	45.00	90.00	135.00																			45.00	90.00	135.00																	45.00			45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1372	002	0	1	01	01	H1372_002_0	7			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1372	002	0	1	01	01	H1372_002_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				562.14	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, 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 Drug, 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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1372	003	0	1	01	01	H1372_003_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				805.26	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1395	001	0	1	04	01	H1395_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					0.00	0.00	0.00												38.00	57.00					0.00	0.00				19.00				19.00			0.63	0.00				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1395	001	0	1	04	01	H1395_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					0.00	0.00	0.00												40.00	60.00					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																														
H1395	001	0	1	04	01	H1395_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											73.12	18	18	18				73.12	18	18	18											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	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	18	18	18	18	18	18		18	18		18	18	18		18
H1395	001	0	1	04	01	H1395_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1395	001	0	1	04	01	H1395_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1395	002	0	1	04	01	H1395_002_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1395	002	0	1	04	01	H1395_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											117.09	25	25	25				117.09	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1395	002	0	1	04	01	H1395_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											53.15	39	39	39				51.79	38	38	38											39	39					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1395	002	0	1	04	01	H1395_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1395	002	0	1	04	01	H1395_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1395	003	0	1	04	01	H1395_003_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											84.00	20	20	20				84.00	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1395	003	0	1	04	01	H1395_003_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											37.17	32	32	32				37.17	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1395	003	0	1	04	01	H1395_003_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1396	001	0	1	01	01	H1396_001_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	0		0				25		25	0		0	0		0
H1396	001	0	1	01	01	H1396_001_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	0		0				25		25	0		0	0		0
H1396	001	0	1	01	01	H1396_001_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1396	001	0	1	01	01	H1396_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1396	001	0	1	01	01	H1396_001_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	25						25			25			25		25
H1416	009	0	1	02	01	H1416_009_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	009	0	1	02	01	H1416_009_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	009	0	1	02	01	H1416_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											111.33	25	25	25				111.33	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	009	0	1	02	01	H1416_009_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.36	50	50	50				97.36	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	009	0	1	02	01	H1416_009_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	009	0	1	02	01	H1416_009_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	026	0	1	02	01	H1416_026_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	026	0	1	02	01	H1416_026_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.46	25	25	25				112.46	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	026	0	1	02	01	H1416_026_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.14	38	38	38				65.37	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	026	0	1	02	01	H1416_026_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	026	0	1	02	01	H1416_026_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	033	0	1	02	01	H1416_033_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	033	0	1	02	01	H1416_033_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	033	0	1	02	01	H1416_033_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											90.66	22	22	22				90.66	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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	22	22	22		22	22		22	22	22		22
H1416	033	0	1	02	01	H1416_033_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	033	0	1	02	01	H1416_033_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	033	0	1	02	01	H1416_033_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	034	0	1	02	01	H1416_034_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	034	0	1	02	01	H1416_034_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	034	0	1	02	01	H1416_034_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.64	20	20	20				83.64	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1416	034	0	1	02	01	H1416_034_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	034	0	1	02	01	H1416_034_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	034	0	1	02	01	H1416_034_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	035	0	1	02	01	H1416_035_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					7.00	14.00	21.00												38.00	57.00					14.00	0.00				19.00				19.00			0.63	0.23				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	035	0	1	02	01	H1416_035_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	035	0	1	02	01	H1416_035_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											85.18	20	20	20				85.18	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1416	035	0	1	02	01	H1416_035_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	035	0	1	02	01	H1416_035_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	035	0	1	02	01	H1416_035_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	042	0	1	02	01	H1416_042_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.72	20	20	20				82.72	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1416	042	0	1	02	01	H1416_042_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											35.37	33	33	33				34.30	32	32	32											33	33					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	042	0	1	02	01	H1416_042_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	043	0	1	02	01	H1416_043_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					6.00	12.00	18.00												38.00	57.00					12.00	0.00				19.00				19.00			0.63	0.20				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	043	0	1	02	01	H1416_043_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	043	0	1	02	01	H1416_043_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											80.85	20	20	20				80.85	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1416	043	0	1	02	01	H1416_043_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	043	0	1	02	01	H1416_043_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	043	0	1	02	01	H1416_043_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	044	0	1	02	01	H1416_044_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					1.00	2.00	3.00												38.00	57.00					2.00	0.00				19.00				19.00			0.63	0.03				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	044	0	1	02	01	H1416_044_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	044	0	1	02	01	H1416_044_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.90	20	20	20				82.90	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1416	044	0	1	02	01	H1416_044_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	044	0	1	02	01	H1416_044_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	044	0	1	02	01	H1416_044_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	055	0	1	02	01	H1416_055_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	055	0	1	02	01	H1416_055_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.32	25	25	25				123.32	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	055	0	1	02	01	H1416_055_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											47.98	38	38	38				46.71	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	055	0	1	02	01	H1416_055_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	055	0	1	02	01	H1416_055_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	064	0	1	02	01	H1416_064_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	064	0	1	02	01	H1416_064_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.42	25	25	25				112.42	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	064	0	1	02	01	H1416_064_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											52.62	48	48	48				52.62	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	064	0	1	02	01	H1416_064_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	064	0	1	02	01	H1416_064_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	065	0	1	02	01	H1416_065_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	065	0	1	02	01	H1416_065_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											109.99	25	25	25				109.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	065	0	1	02	01	H1416_065_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											53.31	50	50	50				53.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	065	0	1	02	01	H1416_065_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	065	0	1	02	01	H1416_065_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	068	0	1	02	01	H1416_068_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.54	22	22	22				89.29	21	21	21											22	22					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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	21	21	21		22	22		21	21	22		22
H1416	068	0	1	02	01	H1416_068_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	068	0	1	02	01	H1416_068_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	071	0	1	02	01	H1416_071_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	071	0	1	02	01	H1416_071_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	071	0	1	02	01	H1416_071_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.29	25	25	25				116.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	071	0	1	02	01	H1416_071_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.27	42	42	42				73.59	40	40	40											42	42					40	40			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	071	0	1	02	01	H1416_071_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	071	0	1	02	01	H1416_071_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	072	0	1	02	01	H1416_072_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	072	0	1	02	01	H1416_072_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											126.99	25	25	25				126.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	072	0	1	02	01	H1416_072_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											59.58	34	34	34				57.82	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	072	0	1	02	01	H1416_072_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	072	0	1	02	01	H1416_072_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	077	0	1	02	01	H1416_077_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	077	0	1	02	01	H1416_077_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											126.83	25	25	25				126.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	077	0	1	02	01	H1416_077_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.96	36	36	36				66.07	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	077	0	1	02	01	H1416_077_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	077	0	1	02	01	H1416_077_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	079	0	1	02	01	H1416_079_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	079	0	1	02	01	H1416_079_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.55	25	25	25				112.55	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	079	0	1	02	01	H1416_079_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.99	50	50	50				74.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	079	0	1	02	01	H1416_079_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	079	0	1	02	01	H1416_079_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	081	0	1	02	01	H1416_081_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	081	0	1	02	01	H1416_081_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	081	0	1	02	01	H1416_081_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.36	24	24	24				93.30	23	23	23											24	24					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		70.00	105.00		70.00	105.00	35.00		35.00	24	24	24	23	23	23		24	24		23	23	24		24
H1416	081	0	1	02	01	H1416_081_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	081	0	1	02	01	H1416_081_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	081	0	1	02	01	H1416_081_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1416	082	0	1	02	01	H1416_082_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1416	082	0	1	02	01	H1416_082_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.39	25	25	25				120.39	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	082	0	1	02	01	H1416_082_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											60.15	34	34	34				60.15	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	082	0	1	02	01	H1416_082_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	082	0	1	02	01	H1416_082_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1416	083	0	1	02	01	H1416_083_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											90.89	21	21	21				90.89	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H1416	083	0	1	02	01	H1416_083_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1416	083	0	1	02	01	H1416_083_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	4			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	001	0	1	02	01	H1423_001_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1423	001	0	1	02	01	H1423_001_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.00	25	25	25				79.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H1423	001	0	1	02	01	H1423_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		34											47.00	30	30	30				30.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1423	001	0	1	02	01	H1423_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1423	001	0	1	02	01	H1423_001_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H1423	002	0	1	02	01	H1423_002_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1423	002	0	1	02	01	H1423_002_0	4			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				86.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H1423	002	0	1	02	01	H1423_002_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1423	002	0	1	02	01	H1423_002_0	4			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																														
H1423	002	0	1	02	01	H1423_002_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H1423	004	0	1	02	01	H1423_004_0	4			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	004	0	1	02	01	H1423_004_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1423	004	0	1	02	01	H1423_004_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.00	25	25	25				103.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H1423	004	0	1	02	01	H1423_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											59.00	30	30	30				39.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1423	004	0	1	02	01	H1423_004_0	4			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																														
H1423	004	0	1	02	01	H1423_004_0	4			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	0	0	0	0	0	0	0	0	0				0		0
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								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			0.29	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	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											74.00	25	25	25				107.00	25	25	25				25	25	25															25			25								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	25	25	25	25	25	25	25	25	25				25		25
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											62.00	30	30	30				35.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
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												31							31						31																	31			31								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	0	0	0	0	0	0	0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																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			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
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				63.00	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		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								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	0	0	0				0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1423	008	0	1	01	01	H1423_008_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				82.00	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
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				60.00	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		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								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	0	0	0				0	0	0				0		0
H1423	009	0	1	02	01	H1423_009_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1423	009	0	1	02	01	H1423_009_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											74.00	25	25	25				96.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H1423	009	0	1	02	01	H1423_009_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	30	30	30				32.00	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	25	25	25	25	25	25	25	25	25				25		25
H1423	009	0	1	02	01	H1423_009_0	4			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																														
H1468	007	0	1	01	01	H1468_007_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	0		0				25		25	0		0	0		0
H1468	007	0	1	01	01	H1468_007_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1468	007	0	1	01	01	H1468_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	25		25				25		25	25		25	25		25
H1468	007	0	1	01	01	H1468_007_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	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	25		25				25		25	25		25	25		25
H1468	007	0	1	01	01	H1468_007_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	25						25			25			25		25
H1468	013	0	1	01	01	H1468_013_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	0		0				25		25	0		0	0		0
H1468	013	0	1	01	01	H1468_013_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1468	013	0	1	01	01	H1468_013_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	25		25				25		25	25		25	25		25
H1468	013	0	1	01	01	H1468_013_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	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	25		25				25		25	25		25	25		25
H1468	013	0	1	01	01	H1468_013_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	25						25			25			25		25
H1468	017	0	1	01	01	H1468_017_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	0		0				25		25	0		0	0		0
H1468	017	0	1	01	01	H1468_017_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	25		25				25		25	25		0	25		25
H1468	017	0	1	01	01	H1468_017_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H1468	017	0	1	01	01	H1468_017_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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	25		25				25		25	25		25	25		25
H1468	017	0	1	01	01	H1468_017_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	25						25			25			25		25
H1468	017	0	1	01	01	H1468_017_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	0		0				0		0	0		0	0		0
H1468	021	0	1	01	01	H1468_021_0	2			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	0		0				25		25	0		0	0		0
H1468	021	0	1	01	01	H1468_021_0	2			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	25		25				25		25	25		0	25		25
H1468	021	0	1	01	01	H1468_021_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1468	021	0	1	01	01	H1468_021_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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	25		25				25		25	25		25	25		25
H1468	021	0	1	01	01	H1468_021_0	2			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	25						25			25			25		25
H1526	001	0	1	02	01	H1526_001_0	5			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	5			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	5			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	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	5			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	25	25	25				25	25	25				25		25
H1526	001	0	1	02	01	H1526_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				426.82	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	5			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	0	0	0				0	0	0				0		0
H1526	002	0	1	02	01	H1526_002_0	5			Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				2.54	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	002	0	1	02	01	H1526_002_0	5			Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.56	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	002	0	1	02	01	H1526_002_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				86.28	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	002	0	1	02	01	H1526_002_0	5			Non-Preferred Brand	4	10	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				55.38	26	26	26																		26	26	26															26			26								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	25	25	25				25	25	25				25		25
H1526	002	0	1	02	01	H1526_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				349.45	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	002	0	1	02	01	H1526_002_0	5			Select Diabetic Drugs	4	11	1	1	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				15.36	15	15	15																		15	15	15															15			15								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	15	15	15				15	15	15				15		15
H1526	003	0	1	02	01	H1526_003_0	5			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	5			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	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	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	5			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	25	25	25				25	25	25				25		25
H1526	003	0	1	02	01	H1526_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				323.35	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	5			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	0	0	0				0	0	0				0		0
H1526	008	0	1	02	01	H1526_008_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	008	0	1	02	01	H1526_008_0	4			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	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	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	4			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	25	25	25				25	25	25				25		25
H1526	008	0	1	02	01	H1526_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				419.73	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	4			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	0	0	0				0	0	0				0		0
H1526	009	0	1	02	01	H1526_009_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H1526	009	0	1	02	01	H1526_009_0	4			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	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	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	4			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	25	25	25				25	25	25				25		25
H1526	009	0	1	02	01	H1526_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				328.93	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	4			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	0	0	0				0	0	0				0		0
H1607	012	0	1	04	01	H1607_012_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								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	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											44.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H1607	012	0	1	04	01	H1607_012_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											37.00	30	30	30				26.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1607	012	0	1	04	01	H1607_012_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1607	012	0	1	04	01	H1607_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	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																														
H1607	015	0	1	04	01	H1607_015_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.00	25	25	25				78.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H1607	015	0	1	04	01	H1607_015_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											32.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1607	015	0	1	04	01	H1607_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1607	015	0	1	04	01	H1607_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.53	24	24	24				89.20	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	001	0	1	04	01	H1608_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											33.66	25	25	25				41.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	001	0	1	04	01	H1608_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											508.04	25						555.96	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	25			25			25			25			25		25
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											64.62	24	24	24				84.92	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.38	25	25	25				41.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											451.88	25						596.67	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	25			25			25			25			25		25
H1608	013	0	1	04	01	H1608_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																														
H1608	013	0	1	04	01	H1608_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																														
H1608	013	0	1	04	01	H1608_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											63.18	24	24	24				89.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	013	0	1	04	01	H1608_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											39.26	25	25	25				45.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	013	0	1	04	01	H1608_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											610.26	25						563.41	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	25			25			25			25			25		25
H1608	016	0	1	04	01	H1608_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																														
H1608	016	0	1	04	01	H1608_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																														
H1608	016	0	1	04	01	H1608_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											61.80	24	24	24				89.53	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	016	0	1	04	01	H1608_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											39.91	25	25	25				44.11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	016	0	1	04	01	H1608_016_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											519.22	25						603.73	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	25			25			25			25			25		25
H1608	017	0	1	04	01	H1608_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																														
H1608	017	0	1	04	01	H1608_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																														
H1608	017	0	1	04	01	H1608_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											62.26	24	24	24				91.06	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	017	0	1	04	01	H1608_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											39.17	25	25	25				43.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	017	0	1	04	01	H1608_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											543.53	25						602.87	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											61.40	24	24	24				87.91	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											32.71	25	25	25				41.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											544.65	25						583.54	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	25			25			25			25			25		25
H1608	021	0	1	04	01	H1608_021_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	021	0	1	04	01	H1608_021_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	021	0	1	04	01	H1608_021_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				82.52	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	021	0	1	04	01	H1608_021_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				41.06	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	021	0	1	04	01	H1608_021_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				541.39	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H1608	024	0	1	04	01	H1608_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																														
H1608	024	0	1	04	01	H1608_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																														
H1608	024	0	1	04	01	H1608_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											65.95	24	24	24				89.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	024	0	1	04	01	H1608_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											33.08	25	25	25				41.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	024	0	1	04	01	H1608_024_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											473.60	25						615.47	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	25			25			25			25			25		25
H1608	027	0	1	04	01	H1608_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																														
H1608	027	0	1	04	01	H1608_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																														
H1608	027	0	1	04	01	H1608_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											77.72	24	24	24				98.95	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	027	0	1	04	01	H1608_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											35.48	25	25	25				39.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	027	0	1	04	01	H1608_027_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											519.24	25						577.30	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	25			25			25			25			25		25
H1608	028	0	1	04	01	H1608_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																														
H1608	028	0	1	04	01	H1608_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																														
H1608	028	0	1	04	01	H1608_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											67.76	24	24	24				93.22	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	028	0	1	04	01	H1608_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											41.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	028	0	1	04	01	H1608_028_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											544.87	25						597.74	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	25			25			25			25			25		25
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											72.03	24	24	24				95.84	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.77	25	25	25				45.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											594.53	25						662.27	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	25			25			25			25			25		25
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											72.06	24	24	24				94.31	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.93	25	25	25				46.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											585.86	25						678.63	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	25			25			25			25			25		25
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											56.42	24	24	24				86.39	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											33.28	25	25	25				40.51	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											482.83	25						527.28	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	25			25			25			25			25		25
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											63.69	24	24	24				84.48	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.05	25	25	25				41.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											514.82	25						693.71	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	25			25			25			25			25		25
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											68.86	24	24	24				93.58	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											34.79	25	25	25				41.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											505.02	25						624.37	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	25			25			25			25			25		25
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											66.50	24	24	24				93.39	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											35.09	25	25	25				44.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											545.35	25						535.71	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	25			25			25			25			25		25
H1608	051	0	1	04	01	H1608_051_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.32	24	24	24				88.76	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	051	0	1	04	01	H1608_051_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											36.43	25	25	25				45.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	051	0	1	04	01	H1608_051_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											541.30	25						627.33	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	25			25			25			25			25		25
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											72.92	24	24	24				94.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.53	25	25	25				42.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											521.04	25						577.25	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	25			25			25			25			25		25
H1608	054	0	1	04	01	H1608_054_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	054	0	1	04	01	H1608_054_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	054	0	1	04	01	H1608_054_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				89.11	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	054	0	1	04	01	H1608_054_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				44.27	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	054	0	1	04	01	H1608_054_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				549.24	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H1608	062	0	1	04	01	H1608_062_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	062	0	1	04	01	H1608_062_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	062	0	1	04	01	H1608_062_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				62.24	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	22	22	22				22	22	22				22		22
H1608	062	0	1	04	01	H1608_062_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				31.77	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	25	25	25				25	25	25				25		25
H1608	062	0	1	04	01	H1608_062_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				411.66	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											58.82	24	24	24				87.46	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.18	25	25	25				45.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											498.90	25						611.34	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	25			25			25			25			25		25
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											61.21	24	24	24				83.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											34.30	25	25	25				39.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											539.05	25						635.52	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	25			25			25			25			25		25
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											66.74	24	24	24				88.61	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.72	25	25	25				43.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											514.15	25						602.49	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	25			25			25			25			25		25
H1608	076	0	1	04	01	H1608_076_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	076	0	1	04	01	H1608_076_0	2		N	Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	076	0	1	04	01	H1608_076_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				62.76	22	22	22																																				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	22	22	22										22		22
H1608	076	0	1	04	01	H1608_076_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				34.00	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	076	0	1	04	01	H1608_076_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				444.10	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H1608	077	0	1	04	01	H1608_077_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	077	0	1	04	01	H1608_077_0	2		N	Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	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																														
H1608	077	0	1	04	01	H1608_077_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				64.19	22	22	22																																				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	22	22	22										22		22
H1608	077	0	1	04	01	H1608_077_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				34.01	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	077	0	1	04	01	H1608_077_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				453.35	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H1608	079	0	1	04	01	H1608_079_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	079	0	1	04	01	H1608_079_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	079	0	1	04	01	H1608_079_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				82.67	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	079	0	1	04	01	H1608_079_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				42.48	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	079	0	1	04	01	H1608_079_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				514.87	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
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											58.11	24	24	24				85.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.48	25	25	25				45.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											507.28	25						606.22	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	25			25			25			25			25		25
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											70.15	24	24	24				93.28	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.58	25	25	25				48.31	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											561.31	25						908.33	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	25			25			25			25			25		25
H1608	105	0	1	04	01	H1608_105_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	105	0	1	04	01	H1608_105_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	105	0	1	04	01	H1608_105_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				79.61	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	105	0	1	04	01	H1608_105_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				42.60	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1608	105	0	1	04	01	H1608_105_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				537.21	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
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											69.55	24	24	24				97.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.64	25	25	25				50.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											581.95	25						707.02	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	25			25			25			25			25		25
H1608	117	0	1	04	01	H1608_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																														
H1608	117	0	1	04	01	H1608_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																														
H1608	117	0	1	04	01	H1608_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											60.56	24	24	24				87.07	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	117	0	1	04	01	H1608_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											38.49	25	25	25				45.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	117	0	1	04	01	H1608_117_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											526.50	25						640.49	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	25			25			25			25			25		25
H1608	118	0	1	04	01	H1608_118_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	118	0	1	04	01	H1608_118_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	118	0	1	04	01	H1608_118_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.55	24	24	24				87.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	118	0	1	04	01	H1608_118_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.54	25	25	25				45.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	118	0	1	04	01	H1608_118_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											528.29	25						644.41	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	25			25			25			25			25		25
H1608	119	0	1	04	01	H1608_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																														
H1608	119	0	1	04	01	H1608_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																														
H1608	119	0	1	04	01	H1608_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											53.56	24	24	24				72.87	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	119	0	1	04	01	H1608_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											33.90	25	25	25				41.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	119	0	1	04	01	H1608_119_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											423.39	25						512.49	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	25			25			25			25			25		25
H1608	120	0	1	04	01	H1608_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																														
H1608	120	0	1	04	01	H1608_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																														
H1608	120	0	1	04	01	H1608_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											60.56	24	24	24				87.12	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1608	120	0	1	04	01	H1608_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											38.52	25	25	25				45.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1608	120	0	1	04	01	H1608_120_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.37	25						642.39	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	25			25			25			25			25		25
H1608	121	0	1	04	01	H1608_121_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	121	0	1	04	01	H1608_121_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1608	121	0	1	04	01	H1608_121_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				62.73	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	22	22	22				22	22	22				22		22
H1608	121	0	1	04	01	H1608_121_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				32.70	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1608	121	0	1	04	01	H1608_121_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				420.79	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											66.76	24	24	24				93.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											33.10	25	25	25				39.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											534.31	25						586.29	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	25			25			25			25			25		25
H1609	017	0	1	01	01	H1609_017_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	017	0	1	01	01	H1609_017_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	017	0	1	01	01	H1609_017_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				75.22	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		35.00	22	22	22				22	22	22				22		22
H1609	017	0	1	01	01	H1609_017_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				42.67	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	017	0	1	01	01	H1609_017_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				542.72	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	018	0	1	01	01	H1609_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																														
H1609	018	0	1	01	01	H1609_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																														
H1609	018	0	1	01	01	H1609_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											42.88	21	21	21				59.88	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H1609	018	0	1	01	01	H1609_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											43.57	33	33	33				36.07	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	018	0	1	01	01	H1609_018_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											593.51	33						742.84	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	25			25			25			25			25		25
H1609	019	0	1	01	01	H1609_019_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	019	0	1	01	01	H1609_019_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	019	0	1	01	01	H1609_019_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				71.37	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	22	22	22				22	22	22				22		22
H1609	019	0	1	01	01	H1609_019_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				40.01	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	019	0	1	01	01	H1609_019_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				525.34	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	020	0	1	01	01	H1609_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																														
H1609	020	0	1	01	01	H1609_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																														
H1609	020	0	1	01	01	H1609_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											40.74	21	21	21				57.57	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H1609	020	0	1	01	01	H1609_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											37.85	33	33	33				34.61	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	020	0	1	01	01	H1609_020_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											659.04	33						757.18	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	25			25			25			25			25		25
H1609	021	0	1	01	01	H1609_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																														
H1609	021	0	1	01	01	H1609_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																														
H1609	021	0	1	01	01	H1609_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											59.64	25	25	25				83.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	021	0	1	01	01	H1609_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											44.11	30	30	30				43.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	021	0	1	01	01	H1609_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											669.64	30						703.49	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	25			25			25			25			25		25
H1609	022	0	1	01	01	H1609_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																														
H1609	022	0	1	01	01	H1609_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																														
H1609	022	0	1	01	01	H1609_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											59.12	25	25	25				79.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	022	0	1	01	01	H1609_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											45.55	30	30	30				45.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	022	0	1	01	01	H1609_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											592.53	30						598.08	30												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	25			25			25			25			25		25
H1609	025	0	1	01	01	H1609_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																														
H1609	025	0	1	01	01	H1609_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																														
H1609	025	0	1	01	01	H1609_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											60.09	25	25	25				83.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	025	0	1	01	01	H1609_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											44.26	30	30	30				46.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	025	0	1	01	01	H1609_025_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											654.46	30						652.70	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	027	0	1	01	01	H1609_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																														
H1609	027	0	1	01	01	H1609_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																														
H1609	027	0	1	01	01	H1609_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											40.87	21	21	21				56.27	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H1609	027	0	1	01	01	H1609_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											34.66	33	33	33				31.43	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	027	0	1	01	01	H1609_027_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											651.51	33						794.13	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	25			25			25			25			25		25
H1609	028	0	1	02	01	H1609_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																														
H1609	028	0	1	02	01	H1609_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																														
H1609	028	0	1	02	01	H1609_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											59.31	24	24	24				88.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H1609	028	0	1	02	01	H1609_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											41.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	028	0	1	02	01	H1609_028_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											563.76	25						671.67	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	25			25			25			25			25		25
H1609	041	0	1	01	01	H1609_041_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	041	0	1	01	01	H1609_041_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	041	0	1	01	01	H1609_041_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.81	25	25	25				86.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	041	0	1	01	01	H1609_041_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											41.64	30	30	30				46.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	041	0	1	01	01	H1609_041_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											627.25	30						677.16	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	25			25			25			25			25		25
H1609	043	0	1	01	01	H1609_043_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	043	0	1	01	01	H1609_043_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	043	0	1	01	01	H1609_043_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				78.61	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	22	22	22				22	22	22				22		22
H1609	043	0	1	01	01	H1609_043_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				39.65	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	25	25	25				25	25	25				25		25
H1609	043	0	1	01	01	H1609_043_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				529.33	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	044	0	1	01	01	H1609_044_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	044	0	1	01	01	H1609_044_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	044	0	1	01	01	H1609_044_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				74.17	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	22	22	22				22	22	22				22		22
H1609	044	0	1	01	01	H1609_044_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				38.40	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		35.00	25	25	25				25	25	25				25		25
H1609	044	0	1	01	01	H1609_044_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				559.75	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	045	0	1	01	01	H1609_045_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	045	0	1	01	01	H1609_045_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	045	0	1	01	01	H1609_045_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				73.93	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	22	22	22				22	22	22				22		22
H1609	045	0	1	01	01	H1609_045_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				41.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	045	0	1	01	01	H1609_045_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				526.19	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	046	0	1	01	01	H1609_046_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	046	0	1	01	01	H1609_046_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	046	0	1	01	01	H1609_046_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				78.70	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	22	22	22				22	22	22				22		22
H1609	046	0	1	01	01	H1609_046_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				40.42	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	046	0	1	01	01	H1609_046_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				550.99	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	047	0	1	01	01	H1609_047_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	047	0	1	01	01	H1609_047_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	047	0	1	01	01	H1609_047_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				73.08	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	22	22	22				22	22	22				22		22
H1609	047	0	1	01	01	H1609_047_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				42.24	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	047	0	1	01	01	H1609_047_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				548.73	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	048	0	1	01	01	H1609_048_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	048	0	1	01	01	H1609_048_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	048	0	1	01	01	H1609_048_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				75.99	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	22	22	22				22	22	22				22		22
H1609	048	0	1	01	01	H1609_048_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				42.39	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	048	0	1	01	01	H1609_048_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				535.42	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	049	0	1	01	01	H1609_049_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	049	0	1	01	01	H1609_049_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	049	0	1	01	01	H1609_049_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				73.61	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	22	22	22				22	22	22				22		22
H1609	049	0	1	01	01	H1609_049_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				38.81	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	049	0	1	01	01	H1609_049_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				531.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	055	0	1	01	01	H1609_055_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	055	0	1	01	01	H1609_055_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	055	0	1	01	01	H1609_055_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				74.52	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	22	22	22				22	22	22				22		22
H1609	055	0	1	01	01	H1609_055_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				40.79	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	25	25	25				25	25	25				25		25
H1609	055	0	1	01	01	H1609_055_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				541.51	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	056	0	1	01	01	H1609_056_0	4		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	056	0	1	01	01	H1609_056_0	4		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	056	0	1	01	01	H1609_056_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				76.90	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	22	22	22				22	22	22				22		22
H1609	056	0	1	01	01	H1609_056_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				39.66	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	25	25	25				25	25	25				25		25
H1609	056	0	1	01	01	H1609_056_0	4		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				522.66	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	059	0	1	01	01	H1609_059_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.56	25	25	25				84.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	059	0	1	01	01	H1609_059_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.57	30	30	30				47.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	059	0	1	01	01	H1609_059_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											590.34	30						747.49	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	25			25			25			25			25		25
H1609	061	0	1	01	01	H1609_061_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	061	0	1	01	01	H1609_061_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	061	0	1	01	01	H1609_061_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				76.09	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	22	22	22				22	22	22				22		22
H1609	061	0	1	01	01	H1609_061_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				39.80	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	061	0	1	01	01	H1609_061_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				529.76	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	062	0	1	01	01	H1609_062_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	062	0	1	01	01	H1609_062_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	062	0	1	01	01	H1609_062_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				77.12	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	22	22	22				22	22	22				22		22
H1609	062	0	1	01	01	H1609_062_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				40.43	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	062	0	1	01	01	H1609_062_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				541.67	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	063	0	1	01	01	H1609_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																														
H1609	063	0	1	01	01	H1609_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																														
H1609	063	0	1	01	01	H1609_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											59.21	25	25	25				80.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	063	0	1	01	01	H1609_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											40.47	30	30	30				44.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	063	0	1	01	01	H1609_063_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											563.54	30						657.25	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	25			25			25			25			25		25
H1609	064	0	1	01	01	H1609_064_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	064	0	1	01	01	H1609_064_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	064	0	1	01	01	H1609_064_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				76.74	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	22	22	22				22	22	22				22		22
H1609	064	0	1	01	01	H1609_064_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				40.33	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	25	25	25				25	25	25				25		25
H1609	064	0	1	01	01	H1609_064_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				560.93	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	068	0	1	02	01	H1609_068_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	068	0	1	02	01	H1609_068_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	068	0	1	02	01	H1609_068_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.62	22	22	22				79.92	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H1609	068	0	1	02	01	H1609_068_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											33.24	25	25	25				43.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	068	0	1	02	01	H1609_068_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											496.03	25						510.36	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	25			25			25			25			25		25
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											55.04	24	24	24				76.75	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											33.04	25	25	25				33.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											559.23	25						588.31	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	25			25			25			25			25		25
H1609	073	0	1	01	01	H1609_073_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	073	0	1	01	01	H1609_073_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	073	0	1	01	01	H1609_073_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				75.65	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	22	22	22				22	22	22				22		22
H1609	073	0	1	01	01	H1609_073_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	073	0	1	01	01	H1609_073_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	074	0	1	01	01	H1609_074_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	074	0	1	01	01	H1609_074_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	074	0	1	01	01	H1609_074_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				75.65	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	22	22	22				22	22	22				22		22
H1609	074	0	1	01	01	H1609_074_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	074	0	1	01	01	H1609_074_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	075	0	1	01	01	H1609_075_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	075	0	1	01	01	H1609_075_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	075	0	1	01	01	H1609_075_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				75.65	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	22	22	22				22	22	22				22		22
H1609	075	0	1	01	01	H1609_075_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	075	0	1	01	01	H1609_075_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	076	0	1	01	01	H1609_076_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	076	0	1	01	01	H1609_076_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	076	0	1	01	01	H1609_076_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				75.65	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	22	22	22				22	22	22				22		22
H1609	076	0	1	01	01	H1609_076_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	076	0	1	01	01	H1609_076_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	077	0	1	01	01	H1609_077_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	077	0	1	01	01	H1609_077_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	077	0	1	01	01	H1609_077_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				75.65	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	22	22	22				22	22	22				22		22
H1609	077	0	1	01	01	H1609_077_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	077	0	1	01	01	H1609_077_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	078	0	1	01	01	H1609_078_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	078	0	1	01	01	H1609_078_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	078	0	1	01	01	H1609_078_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				75.65	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	22	22	22				22	22	22				22		22
H1609	078	0	1	01	01	H1609_078_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	078	0	1	01	01	H1609_078_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	079	0	1	01	01	H1609_079_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	079	0	1	01	01	H1609_079_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	079	0	1	01	01	H1609_079_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				75.65	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	22	22	22				22	22	22				22		22
H1609	079	0	1	01	01	H1609_079_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				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	079	0	1	01	01	H1609_079_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	080	0	1	01	01	H1609_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																														
H1609	080	0	1	01	01	H1609_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																														
H1609	080	0	1	01	01	H1609_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											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	080	0	1	01	01	H1609_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	080	0	1	01	01	H1609_080_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	081	0	1	01	01	H1609_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																														
H1609	081	0	1	01	01	H1609_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	081	0	1	01	01	H1609_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											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	081	0	1	01	01	H1609_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	081	0	1	01	01	H1609_081_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	082	0	1	01	01	H1609_082_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	082	0	1	01	01	H1609_082_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	082	0	1	01	01	H1609_082_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	082	0	1	01	01	H1609_082_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	082	0	1	01	01	H1609_082_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	083	0	1	01	01	H1609_083_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	083	0	1	01	01	H1609_083_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	083	0	1	01	01	H1609_083_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	083	0	1	01	01	H1609_083_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	083	0	1	01	01	H1609_083_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	084	0	1	01	01	H1609_084_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	084	0	1	01	01	H1609_084_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	084	0	1	01	01	H1609_084_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	084	0	1	01	01	H1609_084_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	084	0	1	01	01	H1609_084_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	085	0	1	01	01	H1609_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																														
H1609	085	0	1	01	01	H1609_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	085	0	1	01	01	H1609_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											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	085	0	1	01	01	H1609_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	085	0	1	01	01	H1609_085_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	086	0	1	01	01	H1609_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																														
H1609	086	0	1	01	01	H1609_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																														
H1609	086	0	1	01	01	H1609_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											56.05	25	25	25				81.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	086	0	1	01	01	H1609_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											42.03	30	30	30				47.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	086	0	1	01	01	H1609_086_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											617.45	30						772.76	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	25			25			25			25			25		25
H1609	087	0	1	01	01	H1609_087_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	087	0	1	01	01	H1609_087_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	087	0	1	01	01	H1609_087_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											56.10	25	25	25				81.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	087	0	1	01	01	H1609_087_0	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	30	30	30				47.37	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	087	0	1	01	01	H1609_087_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											616.99	30						771.18	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1609	088	0	1	01	01	H1609_088_0	4		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	088	0	1	01	01	H1609_088_0	4		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	088	0	1	01	01	H1609_088_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				75.65	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	22	22	22				22	22	22				22		22
H1609	088	0	1	01	01	H1609_088_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	088	0	1	01	01	H1609_088_0	4		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	089	0	1	01	01	H1609_089_0	4		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	089	0	1	01	01	H1609_089_0	4		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	089	0	1	01	01	H1609_089_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				75.65	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	22	22	22				22	22	22				22		22
H1609	089	0	1	01	01	H1609_089_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	089	0	1	01	01	H1609_089_0	4		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	090	0	1	01	01	H1609_090_0	4		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	090	0	1	01	01	H1609_090_0	4		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	090	0	1	01	01	H1609_090_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				75.65	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	22	22	22				22	22	22				22		22
H1609	090	0	1	01	01	H1609_090_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	090	0	1	01	01	H1609_090_0	4		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	092	0	1	01	01	H1609_092_0	4		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	092	0	1	01	01	H1609_092_0	4		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1609	092	0	1	01	01	H1609_092_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				75.65	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	22	22	22				22	22	22				22		22
H1609	092	0	1	01	01	H1609_092_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.85	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1609	092	0	1	01	01	H1609_092_0	4		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1609	093	0	1	01	01	H1609_093_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	093	0	1	01	01	H1609_093_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	093	0	1	01	01	H1609_093_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											55.83	25	25	25				81.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	093	0	1	01	01	H1609_093_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.06	30	30	30				47.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	093	0	1	01	01	H1609_093_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											619.69	30						780.66	30												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	25			25			25			25			25		25
H1609	094	0	1	01	01	H1609_094_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	094	0	1	01	01	H1609_094_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	094	0	1	01	01	H1609_094_0	4			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.60	25	25	25				88.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	094	0	1	01	01	H1609_094_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											41.21	30	30	30				50.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1609	094	0	1	01	01	H1609_094_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.96	30						843.04	30												30						30						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H1610	001	0	1	01	01	H1610_001_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1610	001	0	1	01	01	H1610_001_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1610	001	0	1	01	01	H1610_001_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.71	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	22	22	22				22	22	22				22		22
H1610	001	0	1	01	01	H1610_001_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				33.44	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1610	001	0	1	01	01	H1610_001_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				467.65	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1619	001	0	1	04	01	H1619_001_0	20			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	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	20			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	20			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.48	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1619	001	0	1	04	01	H1619_001_0	20			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.11	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	25	25	25				25	25	25				25		25
H1619	001	0	1	04	01	H1619_001_0	20			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1481.66	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1619	002	0	1	04	01	H1619_002_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1619	002	0	1	04	01	H1619_002_0	19			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1619	002	0	1	04	01	H1619_002_0	19			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.09	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	25	25	25				25	25	25				25		25
H1619	002	0	1	04	01	H1619_002_0	19			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.81	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	25	25	25				25	25	25				25		25
H1619	002	0	1	04	01	H1619_002_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1314.06	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1619	003	0	1	04	01	H1619_003_0	20			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	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	20			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																														
H1619	003	0	1	04	01	H1619_003_0	20			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.50	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1619	003	0	1	04	01	H1619_003_0	20			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.24	34	34	34																		34	34	34															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1619	003	0	1	04	01	H1619_003_0	20			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1406.93	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1659	002	0	1	04	01	H1659_002_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1659	002	0	1	04	01	H1659_002_0	4			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																														
H1659	002	0	1	04	01	H1659_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1659	002	0	1	04	01	H1659_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1659	002	0	1	04	01	H1659_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				399.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1664	001	0	1	02	01	H1664_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1664	001	0	1	02	01	H1664_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1664	001	0	1	02	01	H1664_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											125.37	25	25	25				125.37	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	001	0	1	02	01	H1664_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.32	35	35	35				70.26	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	001	0	1	02	01	H1664_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1664	001	0	1	02	01	H1664_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1664	005	0	1	02	01	H1664_005_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											92.41	22	22	22				88.21	21	21	21											22	22					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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	21	21	21		22	22		21	21	22		22
H1664	005	0	1	02	01	H1664_005_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	005	0	1	02	01	H1664_005_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1664	006	0	1	02	01	H1664_006_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1664	006	0	1	02	01	H1664_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.41	25	25	25				119.41	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	006	0	1	02	01	H1664_006_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.74	44	44	44				69.14	43	43	43											44	44					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	006	0	1	02	01	H1664_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1664	006	0	1	02	01	H1664_006_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1664	012	0	1	02	01	H1664_012_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.81	25	25	25				98.81	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	012	0	1	02	01	H1664_012_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1664	012	0	1	02	01	H1664_012_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								4.00	8.00	12.00					0.00	0.00	0.00												8.00	12.00					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																														
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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	003	0	1	04	01	H1666_003_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	003	0	1	04	01	H1666_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											44.92	19	19	19				43.71	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
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											69.92	37	37	37				73.40	35	35	35										37	37	37				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											699.77	27						559.40	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	006	0	1	04	01	H1666_006_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	006	0	1	04	01	H1666_006_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	006	0	1	04	01	H1666_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											42.79	19	19	19				45.57	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H1666	006	0	1	04	01	H1666_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											71.96	37	37	37				73.59	35	35	35										37	37	37				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	006	0	1	04	01	H1666_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											649.84	25						657.52	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	008	0	1	04	01	H1666_008_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	008	0	1	04	01	H1666_008_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	008	0	1	04	01	H1666_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											55.39	21	21	21				54.69	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	19	19	19	21	21	21	19	19	19	21		21
H1666	008	0	1	04	01	H1666_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											70.74	37	37	37				73.53	34	34	34										37	37	37				34	34	34			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	008	0	1	04	01	H1666_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											745.59	25						605.06	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	012	0	1	04	01	H1666_012_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	012	0	1	04	01	H1666_012_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	012	0	1	04	01	H1666_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											32.77	19	19	19				31.92	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H1666	012	0	1	04	01	H1666_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											65.09	38	38	38				72.76	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	012	0	1	04	01	H1666_012_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.89	27						609.56	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	014	0	1	04	01	H1666_014_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	014	0	1	04	01	H1666_014_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	12.00				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	6.00	12.00	18.00	0.00	0.00	0.00	6.00	12.00	12.00	0.00	0.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	014	0	1	04	01	H1666_014_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.87	17	17	17				30.41	15	15	15										17	17	17				15	15	15			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	70.00	35.00	70.00	70.00	35.00		35.00	17	17	17	15	15	15	17	17	17	15	15	15	17		17
H1666	014	0	1	04	01	H1666_014_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											58.95	39	39	39				78.51	35	35	35										39	39	39				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	014	0	1	04	01	H1666_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											492.95	25						490.07	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	016	0	1	04	01	H1666_016_0	6			Preferred Generic	4	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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	016	0	1	04	01	H1666_016_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	12.00				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	6.00	12.00	18.00	0.00	0.00	0.00	6.00	12.00	12.00	0.00	0.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	016	0	1	04	01	H1666_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											30.22	18	18	18				31.21	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	70.00	35.00	70.00	70.00	35.00		35.00	18	18	18	16	16	16	18	18	18	16	16	16	18		18
H1666	016	0	1	04	01	H1666_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											55.10	32	32	32				70.31	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	016	0	1	04	01	H1666_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											409.83	25						558.05	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	019	0	1	04	01	H1666_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	019	0	1	04	01	H1666_019_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	019	0	1	04	01	H1666_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											51.94	20	20	20				46.47	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H1666	019	0	1	04	01	H1666_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											74.61	43	43	43				74.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	019	0	1	04	01	H1666_019_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											724.48	27						698.74	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	020	0	1	04	01	H1666_020_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	020	0	1	04	01	H1666_020_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	020	0	1	04	01	H1666_020_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											56.47	23	23	23				47.74	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	70.00	35.00	70.00	70.00	35.00		35.00	23	23	23	19	19	19	23	23	23	19	19	19	23		23
H1666	020	0	1	04	01	H1666_020_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											75.06	46	46	46				75.61	42	42	42										46	46	46				42	42	42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	020	0	1	04	01	H1666_020_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											742.20	29						709.54	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	021	0	1	04	01	H1666_021_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	021	0	1	04	01	H1666_021_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	12.00				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	6.00	12.00	18.00	0.00	0.00	0.00	6.00	12.00	12.00	0.00	0.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	021	0	1	04	01	H1666_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											50.07	20	20	20				40.41	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	16	16	16	20	20	20	16	16	16	20		20
H1666	021	0	1	04	01	H1666_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											64.43	40	40	40				63.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	021	0	1	04	01	H1666_021_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											564.53	25						567.08	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	022	0	1	04	01	H1666_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	022	0	1	04	01	H1666_022_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	022	0	1	04	01	H1666_022_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											52.04	23	23	23				48.64	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	70.00	35.00	70.00	70.00	35.00		35.00	23	23	23	19	19	19	23	23	23	19	19	19	23		23
H1666	022	0	1	04	01	H1666_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											72.23	41	41	41				75.84	39	39	39										41	41	41				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	022	0	1	04	01	H1666_022_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											684.84	29						611.81	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	023	0	1	04	01	H1666_023_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	023	0	1	04	01	H1666_023_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	023	0	1	04	01	H1666_023_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.54	19	19	19				45.70	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H1666	023	0	1	04	01	H1666_023_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											77.82	41	41	41				80.30	39	39	39										41	41	41				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	023	0	1	04	01	H1666_023_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											706.42	27						586.41	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1666	024	0	1	04	01	H1666_024_0	5			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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	024	0	1	04	01	H1666_024_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	024	0	1	04	01	H1666_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											45.25	20	20	20				46.10	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H1666	024	0	1	04	01	H1666_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											76.08	44	44	44				78.66	41	41	41										44	44	44				41	41	41			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1666	024	0	1	04	01	H1666_024_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											669.93	29						614.10	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1671	001	0	1	01	01	H1671_001_0	6		N	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	0	0	0						0				0		0
H1671	001	0	1	01	01	H1671_001_0	6		N	Generic	4	01	1	1	2	1	111		01	100		1	31	62	93				2	2			93				31		31				14.51	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						105.00				35.00		35.00	25	25	25						25				25		25
H1671	001	0	1	01	01	H1671_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	31	62	93				2	2			93				31		31				148.77	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						105.00				35.00		35.00	25	25	25						25				25		25
H1671	001	0	1	01	01	H1671_001_0	6		N	Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	31	62	93				2	2			93				31		31				71.55	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						105.00				35.00		35.00	25	25	25						25				25		25
H1671	001	0	1	01	01	H1671_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				751.44	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1671	001	0	1	01	01	H1671_001_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	100		1	31	62	93				1	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	0	0	0						0				0		0
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											77.42	24	24	24				98.61	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											33.40	25	25	25				39.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											531.83	25						588.89	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	25			25			25			25			25		25
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											71.39	24	24	24				97.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.25	25	25	25				46.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											546.87	25						655.72	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	25			25			25			25			25		25
H1692	005	0	1	01	01	H1692_005_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1692	005	0	1	01	01	H1692_005_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1692	005	0	1	01	01	H1692_005_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				73.66	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	22	22	22				22	22	22				22		22
H1692	005	0	1	01	01	H1692_005_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				32.27	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1692	005	0	1	01	01	H1692_005_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				458.17	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											71.86	24	24	24				96.93	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.46	25	25	25				46.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											552.93	25						652.23	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	25			25			25			25			25		25
H1722	002	0	1	01	01	H1722_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	1.00	2.00	2.50																			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, Select Care Drugs	1.00	2.00	2.50				1.00	2.00	2.50				1.00		1.00	25	25	25				25	25	25				25		25
H1722	002	0	1	01	01	H1722_002_0	6			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	5.00																			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, Select Care Drugs	2.00	4.00	5.00				2.00	4.00	5.00				2.00		2.00	25	25	25				25	25	25				25		25
H1722	002	0	1	01	01	H1722_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				46.98	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		35.00	19	19	19				19	19	19				19		19
H1722	002	0	1	01	01	H1722_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				27.34	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1722	002	0	1	01	01	H1722_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H1722	002	0	1	01	01	H1722_002_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	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H1787	002	0	1	01	01	H1787_002_0	6			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1787	002	0	1	01	01	H1787_002_0	6			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	25	25	25										25		25
H1787	002	0	1	01	01	H1787_002_0	6			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	25	25	25										25		25
H1787	002	0	1	01	01	H1787_002_0	6			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	25	25	25										25		25
H1787	002	0	1	01	01	H1787_002_0	6			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				541.56	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	6			Select Care Drugs	4	11	1	2	6	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	003	1	1	01	01	H1799_003_1	9		N	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																														
H1799	003	1	1	01	01	H1799_003_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.07	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	003	1	1	01	01	H1799_003_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				31.52	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	20	20	20				20	20	20				20		20
H1799	003	1	1	01	01	H1799_003_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.20	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		35.00	25	25	25				25	25	25				25		25
H1799	003	1	1	01	01	H1799_003_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				511.63	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	25						25						25		25
H1799	003	1	1	01	01	H1799_003_1	9		N	Select Care Drugs	4	01	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																														
H1799	003	2	1	01	01	H1799_003_2	9		N	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																														
H1799	003	2	1	01	01	H1799_003_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.07	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	003	2	1	01	01	H1799_003_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				31.52	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	20	20	20				20	20	20				20		20
H1799	003	2	1	01	01	H1799_003_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.20	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		35.00	25	25	25				25	25	25				25		25
H1799	003	2	1	01	01	H1799_003_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				511.63	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	25						25						25		25
H1799	003	2	1	01	01	H1799_003_2	9		N	Select Care Drugs	4	01	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																														
H1799	003	3	1	01	01	H1799_003_3	9		N	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																														
H1799	003	3	1	01	01	H1799_003_3	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.07	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	003	3	1	01	01	H1799_003_3	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				31.52	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	20	20	20				20	20	20				20		20
H1799	003	3	1	01	01	H1799_003_3	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.20	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		35.00	25	25	25				25	25	25				25		25
H1799	003	3	1	01	01	H1799_003_3	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				511.63	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	25						25						25		25
H1799	003	3	1	01	01	H1799_003_3	9		N	Select Care Drugs	4	01	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																														
H1799	004	0	1	01	01	H1799_004_0	9		N	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																														
H1799	004	0	1	01	01	H1799_004_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.73	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	004	0	1	01	01	H1799_004_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				34.01	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		35.00	20	20	20				20	20	20				20		20
H1799	004	0	1	01	01	H1799_004_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				70.58	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		35.00	25	25	25				25	25	25				25		25
H1799	004	0	1	01	01	H1799_004_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				682.74	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	25						25						25		25
H1799	004	0	1	01	01	H1799_004_0	9		N	Select Care Drugs	4	01	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																														
H1799	005	0	1	01	01	H1799_005_0	9		N	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																														
H1799	005	0	1	01	01	H1799_005_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.73	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1799	005	0	1	01	01	H1799_005_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				34.01	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		35.00	20	20	20				20	20	20				20		20
H1799	005	0	1	01	01	H1799_005_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				70.58	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		35.00	25	25	25				25	25	25				25		25
H1799	005	0	1	01	01	H1799_005_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				682.74	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	25						25						25		25
H1799	005	0	1	01	01	H1799_005_0	9		N	Select Care Drugs	4	01	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																														
H1822	001	0	1	01	01	H1822_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	001	0	1	01	01	H1822_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	001	0	1	01	01	H1822_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											43.56	35	35	35				43.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	001	0	1	01	01	H1822_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	002	0	1	01	01	H1822_002_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	002	0	1	01	01	H1822_002_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	002	0	1	01	01	H1822_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H1822	002	0	1	01	01	H1822_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											44.74	35	35	35				44.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	002	0	1	01	01	H1822_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	005	0	1	02	01	H1822_005_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	005	0	1	02	01	H1822_005_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	005	0	1	02	01	H1822_005_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H1822	005	0	1	02	01	H1822_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											38.78	35	35	35				38.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	005	0	1	02	01	H1822_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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											102.35	25	25	25				102.35	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											59.83	30	30	30				59.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	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																														
H1822	007	0	1	01	01	H1822_007_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	007	0	1	01	01	H1822_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								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	007	0	1	01	01	H1822_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											47.25	35	35	35				47.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	007	0	1	01	01	H1822_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	008	0	1	02	01	H1822_008_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	008	0	1	02	01	H1822_008_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1822	008	0	1	02	01	H1822_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											75.36	25	25	25				75.36	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H1822	008	0	1	02	01	H1822_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											52.53	30	30	30				52.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1822	008	0	1	02	01	H1822_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1846	005	0	1	04	01	H1846_005_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H1846	005	0	1	04	01	H1846_005_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	25	25	25				25	25	25				25		25
H1846	005	0	1	04	01	H1846_005_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				37.84	25	25	25																		25	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	25	25	25				25	25	25				25		25
H1846	005	0	1	04	01	H1846_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				81.16	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H1846	005	0	1	04	01	H1846_005_0	7			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	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	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	25	25	25				0	0	0				25		25
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				40.10	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	25	25	25				25	25	25				25		25
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				79.10	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	25	25	25				25	25	25				25		25
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					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1846	007	0	1	04	01	H1846_007_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	0	0	0				0	0	0				0		0
H1846	007	0	1	04	01	H1846_007_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	25	25	25				0	0	0				25		25
H1846	007	0	1	04	01	H1846_007_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				39.11	25	25	25																		25	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	25	25	25				25	25	25				25		25
H1846	007	0	1	04	01	H1846_007_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				74.08	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	25	25	25				25	25	25				25		25
H1846	007	0	1	04	01	H1846_007_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	35.00						35.00						35.00		35.00	25						25						25		25
H1862	003	0	1	02	01	H1862_003_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	003	0	1	02	01	H1862_003_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	003	0	1	02	01	H1862_003_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.94	20	20	20				78.94	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1862	003	0	1	02	01	H1862_003_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	003	0	1	02	01	H1862_003_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	003	0	1	02	01	H1862_003_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	004	0	1	02	01	H1862_004_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	004	0	1	02	01	H1862_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	004	0	1	02	01	H1862_004_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.90	25	25	25				98.90	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	004	0	1	02	01	H1862_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	004	0	1	02	01	H1862_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	004	0	1	02	01	H1862_004_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00												12.00	18.00					0.00	0.00				6.00				6.00			0.20	0.00				0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	005	0	1	02	01	H1862_005_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1862	005	0	1	02	01	H1862_005_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1862	005	0	1	02	01	H1862_005_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.10	25	25	25				122.10	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	005	0	1	02	01	H1862_005_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											56.02	36	36	36				54.47	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	005	0	1	02	01	H1862_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	005	0	1	02	01	H1862_005_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	006	0	1	02	01	H1862_006_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	006	0	1	02	01	H1862_006_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	006	0	1	02	01	H1862_006_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.05	25	25	25				99.05	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	006	0	1	02	01	H1862_006_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1862	006	0	1	02	01	H1862_006_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1862	006	0	1	02	01	H1862_006_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					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																														
H1889	002	1	1	04	01	H1889_002_1	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	002	1	1	04	01	H1889_002_1	5		N	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																														
H1889	002	1	1	04	01	H1889_002_1	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H1889	002	1	1	04	01	H1889_002_1	5		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	35.00						35.00						35.00		35.00	25						25						25		25
H1889	002	1	1	04	01	H1889_002_1	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				364.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	002	2	1	04	01	H1889_002_2	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	002	2	1	04	01	H1889_002_2	5		N	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																														
H1889	002	2	1	04	01	H1889_002_2	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H1889	002	2	1	04	01	H1889_002_2	5		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	35.00						35.00						35.00		35.00	25						25						25		25
H1889	002	2	1	04	01	H1889_002_2	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				364.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	005	0	1	04	01	H1889_005_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	005	0	1	04	01	H1889_005_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	005	0	1	04	01	H1889_005_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H1889	005	0	1	04	01	H1889_005_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	005	0	1	04	01	H1889_005_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				363.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	007	0	1	04	01	H1889_007_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	007	0	1	04	01	H1889_007_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	007	0	1	04	01	H1889_007_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1889	007	0	1	04	01	H1889_007_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	007	0	1	04	01	H1889_007_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				366.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	008	0	1	04	01	H1889_008_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	008	0	1	04	01	H1889_008_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	008	0	1	04	01	H1889_008_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1889	008	0	1	04	01	H1889_008_0	4		N	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	25						25						25		25
H1889	008	0	1	04	01	H1889_008_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				333.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	009	0	1	04	01	H1889_009_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	009	0	1	04	01	H1889_009_0	4		N	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																														
H1889	009	0	1	04	01	H1889_009_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H1889	009	0	1	04	01	H1889_009_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H1889	009	0	1	04	01	H1889_009_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				364.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	010	0	1	04	01	H1889_010_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	010	0	1	04	01	H1889_010_0	4		N	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																														
H1889	010	0	1	04	01	H1889_010_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H1889	010	0	1	04	01	H1889_010_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	010	0	1	04	01	H1889_010_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	011	0	1	04	01	H1889_011_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	011	0	1	04	01	H1889_011_0	4		N	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																														
H1889	011	0	1	04	01	H1889_011_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H1889	011	0	1	04	01	H1889_011_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	011	0	1	04	01	H1889_011_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	012	0	1	04	01	H1889_012_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	012	0	1	04	01	H1889_012_0	4		N	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																														
H1889	012	0	1	04	01	H1889_012_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H1889	012	0	1	04	01	H1889_012_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				58.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	012	0	1	04	01	H1889_012_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				350.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	013	0	1	04	01	H1889_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	013	0	1	04	01	H1889_013_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	013	0	1	04	01	H1889_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H1889	013	0	1	04	01	H1889_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	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	25						25			25			25		25
H1889	013	0	1	04	01	H1889_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				349.00	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	25						25			25			25		25
H1889	014	0	1	04	01	H1889_014_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	014	0	1	04	01	H1889_014_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	12.00		36.00																					36.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	014	0	1	04	01	H1889_014_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				39.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H1889	014	0	1	04	01	H1889_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				61.00	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	014	0	1	04	01	H1889_014_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	015	0	1	04	01	H1889_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	015	0	1	04	01	H1889_015_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	015	0	1	04	01	H1889_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1889	015	0	1	04	01	H1889_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1889	015	0	1	04	01	H1889_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				351.00	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	25						25			25			25		25
H1889	016	0	1	04	01	H1889_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	016	0	1	04	01	H1889_016_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	016	0	1	04	01	H1889_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1889	016	0	1	04	01	H1889_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1889	016	0	1	04	01	H1889_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H1889	017	0	1	04	01	H1889_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	017	0	1	04	01	H1889_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	017	0	1	04	01	H1889_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H1889	017	0	1	04	01	H1889_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1889	017	0	1	04	01	H1889_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				339.00	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	25						25			25			25		25
H1889	019	0	1	04	01	H1889_019_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	019	0	1	04	01	H1889_019_0	4			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																														
H1889	019	0	1	04	01	H1889_019_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				66.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	25		25						25				25		25
H1889	019	0	1	04	01	H1889_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	019	0	1	04	01	H1889_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				409.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	020	0	1	04	01	H1889_020_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	020	0	1	04	01	H1889_020_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	020	0	1	04	01	H1889_020_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				54.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H1889	020	0	1	04	01	H1889_020_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	48																										48						48					48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1889	020	0	1	04	01	H1889_020_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				390.00	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	25						25			25			25		25
H1889	025	0	1	04	01	H1889_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	025	0	1	04	01	H1889_025_0	4			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																														
H1889	025	0	1	04	01	H1889_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				64.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H1889	025	0	1	04	01	H1889_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				59.00	49																				49																	49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	025	0	1	04	01	H1889_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	026	0	1	04	01	H1889_026_0	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	026	0	1	04	01	H1889_026_0	5		N	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																														
H1889	026	0	1	04	01	H1889_026_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H1889	026	0	1	04	01	H1889_026_0	5		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	35.00						35.00						35.00		35.00	25						25						25		25
H1889	026	0	1	04	01	H1889_026_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	030	0	1	04	01	H1889_030_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	030	0	1	04	01	H1889_030_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	030	0	1	04	01	H1889_030_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H1889	030	0	1	04	01	H1889_030_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	030	0	1	04	01	H1889_030_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				345.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	031	0	1	04	01	H1889_031_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	031	0	1	04	01	H1889_031_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	031	0	1	04	01	H1889_031_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H1889	031	0	1	04	01	H1889_031_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	031	0	1	04	01	H1889_031_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				346.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	032	0	1	04	01	H1889_032_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	032	0	1	04	01	H1889_032_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	032	0	1	04	01	H1889_032_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1889	032	0	1	04	01	H1889_032_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	032	0	1	04	01	H1889_032_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				378.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	034	0	1	04	01	H1889_034_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	034	0	1	04	01	H1889_034_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	034	0	1	04	01	H1889_034_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H1889	034	0	1	04	01	H1889_034_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	034	0	1	04	01	H1889_034_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				356.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	035	0	1	04	01	H1889_035_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1889	035	0	1	04	01	H1889_035_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1889	035	0	1	04	01	H1889_035_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H1889	035	0	1	04	01	H1889_035_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1889	035	0	1	04	01	H1889_035_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				399.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1894	002	0	1	01	01	H1894_002_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H1894	002	0	1	01	01	H1894_002_0	7		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, Select Care Drugs																														
H1894	002	0	1	01	01	H1894_002_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				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1894	002	0	1	01	01	H1894_002_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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1894	002	0	1	01	01	H1894_002_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, Select Care Drugs																														
H1894	002	0	1	01	01	H1894_002_0	7		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																														
H1894	011	0	1	01	01	H1894_011_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1894	011	0	1	01	01	H1894_011_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1894	011	0	1	01	01	H1894_011_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				36.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1894	011	0	1	01	01	H1894_011_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, Select Care Drugs																														
H1894	011	0	1	01	01	H1894_011_0	7		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																														
H1914	001	0	1	04	01	H1914_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1914	001	0	1	04	01	H1914_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1914	001	0	1	04	01	H1914_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.80	25	25	25				112.80	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	001	0	1	04	01	H1914_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											92.69	35	35	35				92.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	001	0	1	04	01	H1914_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	001	0	1	04	01	H1914_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1914	002	0	1	04	01	H1914_002_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1914	002	0	1	04	01	H1914_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.23	25	25	25				119.23	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	002	0	1	04	01	H1914_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.18	36	36	36				83.79	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	002	0	1	04	01	H1914_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	002	0	1	04	01	H1914_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1914	007	0	1	04	01	H1914_007_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1914	007	0	1	04	01	H1914_007_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.32	25	25	25				119.32	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	007	0	1	04	01	H1914_007_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											73.93	37	37	37				69.94	35	35	35											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	007	0	1	04	01	H1914_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	007	0	1	04	01	H1914_007_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	008	0	1	04	01	H1914_008_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	008	0	1	04	01	H1914_008_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	008	0	1	04	01	H1914_008_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.32	25	25	25				100.32	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	008	0	1	04	01	H1914_008_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	008	0	1	04	01	H1914_008_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	008	0	1	04	01	H1914_008_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	009	0	1	04	01	H1914_009_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.92	20	20	20				82.92	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H1914	009	0	1	04	01	H1914_009_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											40.18	32	32	32				40.18	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	009	0	1	04	01	H1914_009_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H1914	010	0	1	04	01	H1914_010_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H1914	010	0	1	04	01	H1914_010_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.21	25	25	25				120.21	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	010	0	1	04	01	H1914_010_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.66	50	50	50				69.66	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H1914	010	0	1	04	01	H1914_010_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1914	010	0	1	04	01	H1914_010_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1947	001	0	1	01	01	H1947_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		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																														
H1947	001	0	1	01	01	H1947_001_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1947	001	0	1	01	01	H1947_001_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				84.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	001	0	1	01	01	H1947_001_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		34				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	001	0	1	01	01	H1947_001_0	5		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																														
H1947	001	0	1	01	01	H1947_001_0	5		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																														
H1947	003	0	1	01	01	H1947_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		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																														
H1947	003	0	1	01	01	H1947_003_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1947	003	0	1	01	01	H1947_003_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	003	0	1	01	01	H1947_003_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		34				27.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	003	0	1	01	01	H1947_003_0	5		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																														
H1947	003	0	1	01	01	H1947_003_0	5		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																														
H1947	004	0	1	01	01	H1947_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		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																														
H1947	004	0	1	01	01	H1947_004_0	5		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, Select Care Drugs																														
H1947	004	0	1	01	01	H1947_004_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				70.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	004	0	1	01	01	H1947_004_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1947	004	0	1	01	01	H1947_004_0	5		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																														
H1947	004	0	1	01	01	H1947_004_0	5		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																														
H1951	013	0	1	01	01	H1951_013_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	0		0				25		25	0		0	0		0
H1951	013	0	1	01	01	H1951_013_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	013	0	1	01	01	H1951_013_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	25		25				25		25	25		25	25		25
H1951	013	0	1	01	01	H1951_013_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	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	25		25				25		25	25		25	25		25
H1951	013	0	1	01	01	H1951_013_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	25						25			25			25		25
H1951	024	0	1	01	01	H1951_024_0	2			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	0		0				25		25	0		0	0		0
H1951	024	0	1	01	01	H1951_024_0	2			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	25		25				25		25	25		0	25		25
H1951	024	0	1	01	01	H1951_024_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	024	0	1	01	01	H1951_024_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	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	25		25				25		25	25		25	25		25
H1951	024	0	1	01	01	H1951_024_0	2			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	25						25			25			25		25
H1951	028	0	1	01	01	H1951_028_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	0		0				25		25	0		0	0		0
H1951	028	0	1	01	01	H1951_028_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	028	0	1	01	01	H1951_028_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	25		25				25		25	25		25	25		25
H1951	028	0	1	01	01	H1951_028_0	3			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	25		25				25		25	25		25	25		25
H1951	028	0	1	01	01	H1951_028_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	25						25			25			25		25
H1951	032	0	1	01	01	H1951_032_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	0		0				25		25	0		0	0		0
H1951	032	0	1	01	01	H1951_032_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	0		0				25		25	0		0	0		0
H1951	032	0	1	01	01	H1951_032_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	032	0	1	01	01	H1951_032_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	032	0	1	01	01	H1951_032_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	25						25			25			25		25
H1951	038	0	1	01	01	H1951_038_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	0		0				25		25	0		0	0		0
H1951	038	0	1	01	01	H1951_038_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	0		0				25		25	0		0	0		0
H1951	038	0	1	01	01	H1951_038_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	25		25				25		25	25		25	25		25
H1951	038	0	1	01	01	H1951_038_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	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	25		25				25		25	25		25	25		25
H1951	038	0	1	01	01	H1951_038_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	25						25			25			25		25
H1951	039	0	1	01	01	H1951_039_0	2			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	0		0				25		25	0		0	0		0
H1951	039	0	1	01	01	H1951_039_0	2			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	0		0				25		25	0		0	0		0
H1951	039	0	1	01	01	H1951_039_0	2			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	25		25				25		25	25		25	25		25
H1951	039	0	1	01	01	H1951_039_0	2			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	25		25				25		25	25		25	25		25
H1951	039	0	1	01	01	H1951_039_0	2			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	25						25			25			25		25
H1951	041	0	1	01	01	H1951_041_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	0		0				25		25	0		0	0		0
H1951	041	0	1	01	01	H1951_041_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	0		0				25		25	0		0	0		0
H1951	041	0	1	01	01	H1951_041_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	041	0	1	01	01	H1951_041_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H1951	041	0	1	01	01	H1951_041_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	25						25			25			25		25
H1951	044	0	1	01	01	H1951_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, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1951	044	0	1	01	01	H1951_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H1951	044	0	1	01	01	H1951_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, Select Care Drugs	30.00		90.00				35.00		105.00	30.00		60.00	30.00		30.00	25		25				25		25	25		25	25		25
H1951	044	0	1	01	01	H1951_044_0	5			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	044	0	1	01	01	H1951_044_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1951	044	0	1	01	01	H1951_044_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	0		0				0		0	0		0	0		0
H1951	047	1	1	01	01	H1951_047_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	0		0				25		25	0		0	0		0
H1951	047	1	1	01	01	H1951_047_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	047	1	1	01	01	H1951_047_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	25		25				25		25	25		25	25		25
H1951	047	1	1	01	01	H1951_047_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	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	25		25				25		25	25		25	25		25
H1951	047	1	1	01	01	H1951_047_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	25						25			25			25		25
H1951	047	2	1	01	01	H1951_047_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	0		0				25		25	0		0	0		0
H1951	047	2	1	01	01	H1951_047_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	047	2	1	01	01	H1951_047_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	25		25				25		25	25		25	25		25
H1951	047	2	1	01	01	H1951_047_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	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	25		25				25		25	25		25	25		25
H1951	047	2	1	01	01	H1951_047_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	25						25			25			25		25
H1951	048	1	1	01	01	H1951_048_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	0		0				25		25	0		0	0		0
H1951	048	1	1	01	01	H1951_048_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	048	1	1	01	01	H1951_048_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	25		25				25		25	25		25	25		25
H1951	048	1	1	01	01	H1951_048_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H1951	048	1	1	01	01	H1951_048_1	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	25						25			25			25		25
H1951	048	2	1	01	01	H1951_048_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	0		0				25		25	0		0	0		0
H1951	048	2	1	01	01	H1951_048_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	048	2	1	01	01	H1951_048_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	25		25				25		25	25		25	25		25
H1951	048	2	1	01	01	H1951_048_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H1951	048	2	1	01	01	H1951_048_2	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	25						25			25			25		25
H1951	049	1	1	01	01	H1951_049_1	2			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	0		0				25		25	0		0	0		0
H1951	049	1	1	01	01	H1951_049_1	2			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	25		25				25		25	25		0	25		25
H1951	049	1	1	01	01	H1951_049_1	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	049	1	1	01	01	H1951_049_1	2			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	25		25				25		25	25		25	25		25
H1951	049	1	1	01	01	H1951_049_1	2			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	25						25			25			25		25
H1951	049	2	1	01	01	H1951_049_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	0		0				25		25	0		0	0		0
H1951	049	2	1	01	01	H1951_049_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	049	2	1	01	01	H1951_049_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	25		25				25		25	25		25	25		25
H1951	049	2	1	01	01	H1951_049_2	3			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	25		25				25		25	25		25	25		25
H1951	049	2	1	01	01	H1951_049_2	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	25						25			25			25		25
H1951	049	3	1	01	01	H1951_049_3	2			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	0		0				25		25	0		0	0		0
H1951	049	3	1	01	01	H1951_049_3	2			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	25		25				25		25	25		0	25		25
H1951	049	3	1	01	01	H1951_049_3	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	049	3	1	01	01	H1951_049_3	2			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	25		25				25		25	25		25	25		25
H1951	049	3	1	01	01	H1951_049_3	2			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	25						25			25			25		25
H1951	051	0	1	01	01	H1951_051_0	2			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	0		0				25		25	0		0	0		0
H1951	051	0	1	01	01	H1951_051_0	2			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	25		25				25		25	25		0	25		25
H1951	051	0	1	01	01	H1951_051_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	051	0	1	01	01	H1951_051_0	2			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	25		25				25		25	25		25	25		25
H1951	051	0	1	01	01	H1951_051_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	25						25			25			25		25
H1951	052	0	1	01	01	H1951_052_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	0		0				25		25	0		0	0		0
H1951	052	0	1	01	01	H1951_052_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H1951	052	0	1	01	01	H1951_052_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	25		25				25		25	25		25	25		25
H1951	052	0	1	01	01	H1951_052_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	052	0	1	01	01	H1951_052_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	25						25			25			25		25
H1951	053	0	1	01	01	H1951_053_0	2			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	0		0				25		25	0		0	0		0
H1951	053	0	1	01	01	H1951_053_0	2			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	25		25				25		25	25		0	25		25
H1951	053	0	1	01	01	H1951_053_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	053	0	1	01	01	H1951_053_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H1951	053	0	1	01	01	H1951_053_0	2			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	25						25			25			25		25
H1951	056	0	1	01	01	H1951_056_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	0		0				25		25	0		0	0		0
H1951	056	0	1	01	01	H1951_056_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	0		0				25		25	0		0	0		0
H1951	056	0	1	01	01	H1951_056_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	056	0	1	01	01	H1951_056_0	5		N	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	25		25				25		25	25		25	25		25
H1951	056	0	1	01	01	H1951_056_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	25						25			25			25		25
H1951	057	0	1	01	01	H1951_057_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	0		0				25		25	0		0	0		0
H1951	057	0	1	01	01	H1951_057_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	0		0				25		25	0		0	0		0
H1951	057	0	1	01	01	H1951_057_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	057	0	1	01	01	H1951_057_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H1951	057	0	1	01	01	H1951_057_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	25						25			25			25		25
H1951	058	0	1	01	01	H1951_058_0	2			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	0		0				25		25	0		0	0		0
H1951	058	0	1	01	01	H1951_058_0	2			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	0		0				25		25	0		0	0		0
H1951	058	0	1	01	01	H1951_058_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	058	0	1	01	01	H1951_058_0	2			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	25		25				25		25	25		25	25		25
H1951	058	0	1	01	01	H1951_058_0	2			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	25						25			25			25		25
H1951	059	0	1	01	01	H1951_059_0	2			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	0		0				25		25	0		0	0		0
H1951	059	0	1	01	01	H1951_059_0	2			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	0		0				25		25	0		0	0		0
H1951	059	0	1	01	01	H1951_059_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H1951	059	0	1	01	01	H1951_059_0	2			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	25		25				25		25	25		25	25		25
H1951	059	0	1	01	01	H1951_059_0	2			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	25						25			25			25		25
H1951	061	0	1	01	01	H1951_061_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	0		0				25		25	0		0	0		0
H1951	061	0	1	01	01	H1951_061_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	0		0				25		25	0		0	0		0
H1951	061	0	1	01	01	H1951_061_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H1951	061	0	1	01	01	H1951_061_0	4		N	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	25		25				25		25	25		25	25		25
H1951	061	0	1	01	01	H1951_061_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	25						25			25			25		25
H1961	003	0	1	02	01	H1961_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1961	003	0	1	02	01	H1961_003_0	4		N	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																														
H1961	003	0	1	02	01	H1961_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				60.00	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	25		25						25				25		25
H1961	003	0	1	02	01	H1961_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	003	0	1	02	01	H1961_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	014	1	1	02	01	H1961_014_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	1	1	02	01	H1961_014_1	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	1	1	02	01	H1961_014_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H1961	014	1	1	02	01	H1961_014_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	014	1	1	02	01	H1961_014_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H1961	014	2	1	02	01	H1961_014_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	2	1	02	01	H1961_014_2	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	2	1	02	01	H1961_014_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H1961	014	2	1	02	01	H1961_014_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	014	2	1	02	01	H1961_014_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H1961	014	3	1	02	01	H1961_014_3	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	3	1	02	01	H1961_014_3	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	3	1	02	01	H1961_014_3	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H1961	014	3	1	02	01	H1961_014_3	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	014	3	1	02	01	H1961_014_3	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H1961	014	4	1	02	01	H1961_014_4	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	4	1	02	01	H1961_014_4	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	014	4	1	02	01	H1961_014_4	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H1961	014	4	1	02	01	H1961_014_4	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	014	4	1	02	01	H1961_014_4	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H1961	017	0	1	02	01	H1961_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	017	0	1	02	01	H1961_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	017	0	1	02	01	H1961_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H1961	017	0	1	02	01	H1961_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				59.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	017	0	1	02	01	H1961_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
H1961	019	0	1	02	01	H1961_019_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1961	019	0	1	02	01	H1961_019_0	4		N	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																														
H1961	019	0	1	02	01	H1961_019_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H1961	019	0	1	02	01	H1961_019_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	019	0	1	02	01	H1961_019_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				373.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	020	0	1	02	01	H1961_020_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	020	0	1	02	01	H1961_020_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	020	0	1	02	01	H1961_020_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H1961	020	0	1	02	01	H1961_020_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	020	0	1	02	01	H1961_020_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				422.00	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	25						25			25			25		25
H1961	022	0	1	02	01	H1961_022_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	022	0	1	02	01	H1961_022_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	022	0	1	02	01	H1961_022_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				72.00	23		23																										23						23			23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	23		23						23			23	23		23
H1961	022	0	1	02	01	H1961_022_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	46																										46						46					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	022	0	1	02	01	H1961_022_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				374.00	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	25						25			25			25		25
H1961	023	0	1	02	01	H1961_023_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	023	0	1	02	01	H1961_023_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	023	0	1	02	01	H1961_023_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				64.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H1961	023	0	1	02	01	H1961_023_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	46																										46						46					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	023	0	1	02	01	H1961_023_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H1961	024	0	1	02	01	H1961_024_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H1961	024	0	1	02	01	H1961_024_0	4		N	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																														
H1961	024	0	1	02	01	H1961_024_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H1961	024	0	1	02	01	H1961_024_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	024	0	1	02	01	H1961_024_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H1961	025	0	1	02	01	H1961_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	025	0	1	02	01	H1961_025_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1961	025	0	1	02	01	H1961_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				75.00	24		24																										24						24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	24		24						24			24	24		24
H1961	025	0	1	02	01	H1961_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H1961	025	0	1	02	01	H1961_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	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	25						25			25			25		25
H1993	001	0	1	01	01	H1993_001_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, Select Care Drugs																														
H1993	001	0	1	01	01	H1993_001_0	5			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																														
H1993	001	0	1	01	01	H1993_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	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	25	25	25				25	25	25				25		25
H1993	001	0	1	01	01	H1993_001_0	5			Non-Preferred Drug	4	11	1	2	4	1	111		01	000		1	30	60	90				2	2							30		31	98.00	196.00	294.00																																					98.00				98.00		3.27						3.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H1993	001	0	1	01	01	H1993_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				384.18	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	001	0	1	01	01	H1993_001_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	007	0	1	01	01	H1993_007_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, Select Care Drugs																														
H1993	007	0	1	01	01	H1993_007_0	6			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																														
H1993	007	0	1	01	01	H1993_007_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	50.00																			20.00	40.00	40.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	50.00				20.00	40.00	40.00				20.00		20.00	25	25	25				25	25	25				25		25
H1993	007	0	1	01	01	H1993_007_0	6			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	75.00																																							75.00				75.00		2.50						2.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	007	0	1	01	01	H1993_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				619.33	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	007	0	1	01	01	H1993_007_0	6			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	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, Select Care Drugs																														
H1993	008	0	1	01	01	H1993_008_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																			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, Select Care Drugs																														
H1993	008	0	1	01	01	H1993_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	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	25	25	25				25	25	25				25		25
H1993	008	0	1	01	01	H1993_008_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	008	0	1	01	01	H1993_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				294.04	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	008	0	1	01	01	H1993_008_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	011	0	1	01	01	H1993_011_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, Select Care Drugs																														
H1993	011	0	1	01	01	H1993_011_0	5			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																														
H1993	011	0	1	01	01	H1993_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	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	25	25	25				25	25	25				25		25
H1993	011	0	1	01	01	H1993_011_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	011	0	1	01	01	H1993_011_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				807.64	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	011	0	1	01	01	H1993_011_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	012	0	1	01	01	H1993_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, Select Care Drugs																														
H1993	012	0	1	01	01	H1993_012_0	5			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																			5.00	5.00	5.00																0.00				0.00		0.00			0.17			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	012	0	1	01	01	H1993_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	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	25	25	25				25	25	25				25		25
H1993	012	0	1	01	01	H1993_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	012	0	1	01	01	H1993_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				954.55	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	012	0	1	01	01	H1993_012_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	013	0	1	01	01	H1993_013_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, Select Care Drugs																														
H1993	013	0	1	01	01	H1993_013_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																			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																														
H1993	013	0	1	01	01	H1993_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	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	25	25	25				25	25	25				25		25
H1993	013	0	1	01	01	H1993_013_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	100.00																																							100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	013	0	1	01	01	H1993_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				490.19	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	013	0	1	01	01	H1993_013_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	015	0	1	01	01	H1993_015_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, Select Care Drugs																														
H1993	015	0	1	01	01	H1993_015_0	5			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																														
H1993	015	0	1	01	01	H1993_015_0	5			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	25	25	25				25	25	25				25		25
H1993	015	0	1	01	01	H1993_015_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	000		1	30														30		31	95.00																																							95.00				95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H1993	015	0	1	01	01	H1993_015_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				954.55	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1993	015	0	1	01	01	H1993_015_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H1994	001	0	1	01	01	H1994_001_0	4			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	001	0	1	01	01	H1994_001_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																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	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.06	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	001	0	1	01	01	H1994_001_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				80.34	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	25	25	25				25	25	25				25		25
H1994	001	0	1	01	01	H1994_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				462.63	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	012	0	1	01	01	H1994_012_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	012	0	1	01	01	H1994_012_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																														
H1994	012	0	1	01	01	H1994_012_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				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	012	0	1	01	01	H1994_012_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				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	25	25	25				25	25	25				25		25
H1994	012	0	1	01	01	H1994_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				534.79	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	017	0	1	01	01	H1994_017_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	017	0	1	01	01	H1994_017_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																			4.00	8.00	12.00																5.00				5.00		0.17			0.13			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	017	0	1	01	01	H1994_017_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				40.75	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	017	0	1	01	01	H1994_017_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				92.34	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	25	25	25				25	25	25				25		25
H1994	017	0	1	01	01	H1994_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				428.33	29																				29																	29			29								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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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											499.45	30						499.45	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	022	0	1	01	01	H1994_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			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	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					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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											41.34	25	25	25				42.18	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	25	25	25	20	20	20	20	20	20				25		25
H1994	022	0	1	01	01	H1994_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											94.81	35	35	35				71.57	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H1994	022	0	1	01	01	H1994_022_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											462.76	30						462.76	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	027	0	1	01	01	H1994_027_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	027	0	1	01	01	H1994_027_0	6			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	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				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	027	0	1	01	01	H1994_027_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				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	25	25	25				25	25	25				25		25
H1994	027	0	1	01	01	H1994_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				569.23	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	029	0	1	01	01	H1994_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																														
H1994	029	0	1	01	01	H1994_029_0	6			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	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				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	029	0	1	01	01	H1994_029_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	100.00	200.00	300.00																			100.00	200.00	300.00																100.00				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	25	25	25				25	25	25				25		25
H1994	029	0	1	01	01	H1994_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				525.40	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	030	0	1	01	01	H1994_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			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	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					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	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					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	25	25	25	25	25	25	25	25	25				25		25
H1994	030	0	1	01	01	H1994_030_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	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	25	25	25	25	25	25	25	25	25				25		25
H1994	030	0	1	01	01	H1994_030_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											450.74	33						450.74	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	031	0	1	01	01	H1994_031_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	031	0	1	01	01	H1994_031_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	6.00	12.00	18.00																			0.00	0.00	0.00																6.00				6.00		0.20			0.00			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	031	0	1	01	01	H1994_031_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				32.32	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	031	0	1	01	01	H1994_031_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				68.96	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	25	25	25				25	25	25				25		25
H1994	031	0	1	01	01	H1994_031_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				500.14	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	034	0	1	01	01	H1994_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			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	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					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	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					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	25	25	25	25	25	25	25	25	25				25		25
H1994	034	0	1	01	01	H1994_034_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					90.00	180.00	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	25	25	25	25	25	25	25	25	25				25		25
H1994	034	0	1	01	01	H1994_034_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											558.89	33						558.89	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	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	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				32.18	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	25	25	25				25	25	25				25		25
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				89.85	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	25	25	25				25	25	25				25		25
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				587.08	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	044	0	1	01	01	H1994_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																														
H1994	044	0	1	01	01	H1994_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				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1994	044	0	1	01	01	H1994_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				44.14	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H1994	044	0	1	01	01	H1994_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				91.01	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	25	25	25				25	25	25				25		25
H1994	044	0	1	01	01	H1994_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1081.04	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H1997	013	0	1	01	01	H1997_013_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1997	013	0	1	01	01	H1997_013_0	5			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					4.00	8.00	12.00											8.00	16.00	24.00				4.00	8.00	0.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	24.00	4.00	8.00	12.00	8.00	16.00	24.00	4.00	8.00	0.00	8.00		8.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1997	013	0	1	01	01	H1997_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											32.49	25	25	25				32.49	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
H1997	013	0	1	01	01	H1997_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											67.02	43	43	43				67.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H1997	013	0	1	01	01	H1997_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											864.38	30						864.38	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	010	0	1	04	01	H2001_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																														
H2001	010	0	1	04	01	H2001_010_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						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	010	0	1	04	01	H2001_010_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	010	0	1	04	01	H2001_010_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	010	0	1	04	01	H2001_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				329.00	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	25						25			25			25		25
H2001	017	0	1	04	01	H2001_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	017	0	1	04	01	H2001_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	017	0	1	04	01	H2001_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	017	0	1	04	01	H2001_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	017	0	1	04	01	H2001_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H2001	019	0	1	04	01	H2001_019_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	019	0	1	04	01	H2001_019_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	019	0	1	04	01	H2001_019_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	019	0	1	04	01	H2001_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	019	0	1	04	01	H2001_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H2001	023	0	1	04	01	H2001_023_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	023	0	1	04	01	H2001_023_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	023	0	1	04	01	H2001_023_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	023	0	1	04	01	H2001_023_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	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	25						25			25			25		25
H2001	023	0	1	04	01	H2001_023_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				344.00	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	25						25			25			25		25
H2001	030	0	1	04	01	H2001_030_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	030	0	1	04	01	H2001_030_0	4		N	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	030	0	1	04	01	H2001_030_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	030	0	1	04	01	H2001_030_0	4		N	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	25						25						25		25
H2001	030	0	1	04	01	H2001_030_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	031	0	1	04	01	H2001_031_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	031	0	1	04	01	H2001_031_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	031	0	1	04	01	H2001_031_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	031	0	1	04	01	H2001_031_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				52.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	031	0	1	04	01	H2001_031_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	032	0	1	04	01	H2001_032_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	032	0	1	04	01	H2001_032_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	032	0	1	04	01	H2001_032_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	032	0	1	04	01	H2001_032_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	032	0	1	04	01	H2001_032_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	034	0	1	04	01	H2001_034_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	034	0	1	04	01	H2001_034_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				3.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	034	0	1	04	01	H2001_034_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	034	0	1	04	01	H2001_034_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	034	0	1	04	01	H2001_034_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				363.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	035	0	1	04	01	H2001_035_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	035	0	1	04	01	H2001_035_0	4		N	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	035	0	1	04	01	H2001_035_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	035	0	1	04	01	H2001_035_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2001	035	0	1	04	01	H2001_035_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	037	0	1	04	01	H2001_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	037	0	1	04	01	H2001_037_0	4			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	037	0	1	04	01	H2001_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				64.00	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	25		25						25				25		25
H2001	037	0	1	04	01	H2001_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	037	0	1	04	01	H2001_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				368.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	038	0	1	04	01	H2001_038_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	038	0	1	04	01	H2001_038_0	4			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	038	0	1	04	01	H2001_038_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				67.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H2001	038	0	1	04	01	H2001_038_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	038	0	1	04	01	H2001_038_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				384.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	039	0	1	04	01	H2001_039_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	039	0	1	04	01	H2001_039_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	039	0	1	04	01	H2001_039_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	039	0	1	04	01	H2001_039_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	039	0	1	04	01	H2001_039_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				346.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	040	0	1	04	01	H2001_040_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	040	0	1	04	01	H2001_040_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	040	0	1	04	01	H2001_040_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H2001	040	0	1	04	01	H2001_040_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	040	0	1	04	01	H2001_040_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	041	0	1	04	01	H2001_041_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	041	0	1	04	01	H2001_041_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	041	0	1	04	01	H2001_041_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H2001	041	0	1	04	01	H2001_041_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	041	0	1	04	01	H2001_041_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				391.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	042	0	1	04	01	H2001_042_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	042	0	1	04	01	H2001_042_0	4			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	042	0	1	04	01	H2001_042_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				64.00	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	25		25						25				25		25
H2001	042	0	1	04	01	H2001_042_0	4			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	35.00						35.00						35.00		35.00	25						25						25		25
H2001	042	0	1	04	01	H2001_042_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				377.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	044	0	1	04	01	H2001_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	044	0	1	04	01	H2001_044_0	4			Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	044	0	1	04	01	H2001_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				66.00	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	25		25						25				25		25
H2001	044	0	1	04	01	H2001_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	044	0	1	04	01	H2001_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	046	0	1	04	01	H2001_046_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	046	0	1	04	01	H2001_046_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	046	0	1	04	01	H2001_046_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	046	0	1	04	01	H2001_046_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	046	0	1	04	01	H2001_046_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				361.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	047	0	1	04	01	H2001_047_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	047	0	1	04	01	H2001_047_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	047	0	1	04	01	H2001_047_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	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	25		25						25				25		25
H2001	047	0	1	04	01	H2001_047_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	047	0	1	04	01	H2001_047_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				349.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	048	0	1	04	01	H2001_048_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	048	0	1	04	01	H2001_048_0	4		N	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	048	0	1	04	01	H2001_048_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	048	0	1	04	01	H2001_048_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2001	048	0	1	04	01	H2001_048_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				389.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	049	0	1	04	01	H2001_049_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	049	0	1	04	01	H2001_049_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	049	0	1	04	01	H2001_049_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H2001	049	0	1	04	01	H2001_049_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	049	0	1	04	01	H2001_049_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				368.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	051	0	1	04	01	H2001_051_0	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	051	0	1	04	01	H2001_051_0	5		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	051	0	1	04	01	H2001_051_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	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	25		25						25				25		25
H2001	051	0	1	04	01	H2001_051_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	051	0	1	04	01	H2001_051_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	052	0	1	04	01	H2001_052_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	052	0	1	04	01	H2001_052_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	052	0	1	04	01	H2001_052_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	052	0	1	04	01	H2001_052_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	052	0	1	04	01	H2001_052_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				355.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	053	0	1	04	01	H2001_053_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	053	0	1	04	01	H2001_053_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	053	0	1	04	01	H2001_053_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H2001	053	0	1	04	01	H2001_053_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	053	0	1	04	01	H2001_053_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	054	0	1	04	01	H2001_054_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	054	0	1	04	01	H2001_054_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	054	0	1	04	01	H2001_054_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	054	0	1	04	01	H2001_054_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	054	0	1	04	01	H2001_054_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				346.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	055	0	1	04	01	H2001_055_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	055	0	1	04	01	H2001_055_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	055	0	1	04	01	H2001_055_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				56.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H2001	055	0	1	04	01	H2001_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				55.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	055	0	1	04	01	H2001_055_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H2001	056	0	1	04	01	H2001_056_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	056	0	1	04	01	H2001_056_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	056	0	1	04	01	H2001_056_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	056	0	1	04	01	H2001_056_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	056	0	1	04	01	H2001_056_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				362.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	058	0	1	04	01	H2001_058_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H2001	058	0	1	04	01	H2001_058_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	058	0	1	04	01	H2001_058_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H2001	058	0	1	04	01	H2001_058_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	058	0	1	04	01	H2001_058_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	059	0	1	04	01	H2001_059_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	059	0	1	04	01	H2001_059_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	059	0	1	04	01	H2001_059_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				63.00	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	25		25						25				25		25
H2001	059	0	1	04	01	H2001_059_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	059	0	1	04	01	H2001_059_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				410.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	060	0	1	04	01	H2001_060_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	060	0	1	04	01	H2001_060_0	4			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																														
H2001	060	0	1	04	01	H2001_060_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				60.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	22		22						22				22		22
H2001	060	0	1	04	01	H2001_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				73.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	060	0	1	04	01	H2001_060_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				403.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	061	0	1	04	01	H2001_061_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	061	0	1	04	01	H2001_061_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				3.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	061	0	1	04	01	H2001_061_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H2001	061	0	1	04	01	H2001_061_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	061	0	1	04	01	H2001_061_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				291.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	062	0	1	04	01	H2001_062_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	062	0	1	04	01	H2001_062_0	4		N	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	062	0	1	04	01	H2001_062_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	062	0	1	04	01	H2001_062_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	062	0	1	04	01	H2001_062_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	063	1	1	04	01	H2001_063_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	063	1	1	04	01	H2001_063_1	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	063	1	1	04	01	H2001_063_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	063	1	1	04	01	H2001_063_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	063	1	1	04	01	H2001_063_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	063	2	1	04	01	H2001_063_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	063	2	1	04	01	H2001_063_2	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	063	2	1	04	01	H2001_063_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2001	063	2	1	04	01	H2001_063_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	063	2	1	04	01	H2001_063_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	065	0	1	04	01	H2001_065_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	065	0	1	04	01	H2001_065_0	4		N	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	065	0	1	04	01	H2001_065_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	065	0	1	04	01	H2001_065_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	065	0	1	04	01	H2001_065_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	066	0	1	04	01	H2001_066_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	066	0	1	04	01	H2001_066_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	066	0	1	04	01	H2001_066_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	066	0	1	04	01	H2001_066_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				51.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	066	0	1	04	01	H2001_066_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	068	1	1	04	01	H2001_068_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	068	1	1	04	01	H2001_068_1	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	068	1	1	04	01	H2001_068_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	068	1	1	04	01	H2001_068_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	068	1	1	04	01	H2001_068_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	068	2	1	04	01	H2001_068_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	068	2	1	04	01	H2001_068_2	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	068	2	1	04	01	H2001_068_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	068	2	1	04	01	H2001_068_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	068	2	1	04	01	H2001_068_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	069	1	1	04	01	H2001_069_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	069	1	1	04	01	H2001_069_1	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	069	1	1	04	01	H2001_069_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	069	1	1	04	01	H2001_069_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	069	1	1	04	01	H2001_069_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				381.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	069	2	1	04	01	H2001_069_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	069	2	1	04	01	H2001_069_2	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	069	2	1	04	01	H2001_069_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	069	2	1	04	01	H2001_069_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	069	2	1	04	01	H2001_069_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				381.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	070	0	1	04	01	H2001_070_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	070	0	1	04	01	H2001_070_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	070	0	1	04	01	H2001_070_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H2001	070	0	1	04	01	H2001_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	070	0	1	04	01	H2001_070_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				400.00	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	25						25			25			25		25
H2001	075	0	1	04	01	H2001_075_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	075	0	1	04	01	H2001_075_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	075	0	1	04	01	H2001_075_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	075	0	1	04	01	H2001_075_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	075	0	1	04	01	H2001_075_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				377.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	077	0	1	04	01	H2001_077_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	077	0	1	04	01	H2001_077_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	077	0	1	04	01	H2001_077_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H2001	077	0	1	04	01	H2001_077_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	077	0	1	04	01	H2001_077_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				387.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	078	0	1	04	01	H2001_078_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	078	0	1	04	01	H2001_078_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	078	0	1	04	01	H2001_078_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H2001	078	0	1	04	01	H2001_078_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	078	0	1	04	01	H2001_078_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	079	0	1	04	01	H2001_079_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	079	0	1	04	01	H2001_079_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				3.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	079	0	1	04	01	H2001_079_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2001	079	0	1	04	01	H2001_079_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	079	0	1	04	01	H2001_079_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	080	0	1	04	01	H2001_080_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	080	0	1	04	01	H2001_080_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	080	0	1	04	01	H2001_080_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H2001	080	0	1	04	01	H2001_080_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	080	0	1	04	01	H2001_080_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	081	0	1	04	01	H2001_081_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	081	0	1	04	01	H2001_081_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	081	0	1	04	01	H2001_081_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H2001	081	0	1	04	01	H2001_081_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	081	0	1	04	01	H2001_081_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				385.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	082	0	1	04	01	H2001_082_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	082	0	1	04	01	H2001_082_0	4		N	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	082	0	1	04	01	H2001_082_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2001	082	0	1	04	01	H2001_082_0	4		N	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	25						25						25		25
H2001	082	0	1	04	01	H2001_082_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	083	1	1	04	01	H2001_083_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	083	1	1	04	01	H2001_083_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	083	1	1	04	01	H2001_083_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	083	1	1	04	01	H2001_083_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	083	1	1	04	01	H2001_083_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H2001	083	2	1	04	01	H2001_083_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	083	2	1	04	01	H2001_083_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	083	2	1	04	01	H2001_083_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	083	2	1	04	01	H2001_083_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	083	2	1	04	01	H2001_083_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H2001	084	0	1	04	01	H2001_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																														
H2001	084	0	1	04	01	H2001_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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	084	0	1	04	01	H2001_084_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	084	0	1	04	01	H2001_084_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	084	0	1	04	01	H2001_084_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	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	25						25			25			25		25
H2001	085	0	1	04	01	H2001_085_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2001	085	0	1	04	01	H2001_085_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	085	0	1	04	01	H2001_085_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				42.00	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	25		25						25				25		25
H2001	085	0	1	04	01	H2001_085_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				37.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	085	0	1	04	01	H2001_085_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				312.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	087	0	1	04	01	H2001_087_0	3			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	087	0	1	04	01	H2001_087_0	3			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	087	0	1	04	01	H2001_087_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	087	0	1	04	01	H2001_087_0	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				369.00	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	25						25			25			25		25
H2001	090	0	1	04	01	H2001_090_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	090	0	1	04	01	H2001_090_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	090	0	1	04	01	H2001_090_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	090	0	1	04	01	H2001_090_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	090	0	1	04	01	H2001_090_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				412.00	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	25						25			25			25		25
H2001	094	0	1	04	01	H2001_094_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	094	0	1	04	01	H2001_094_0	4			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																														
H2001	094	0	1	04	01	H2001_094_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2001	094	0	1	04	01	H2001_094_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				79.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	094	0	1	04	01	H2001_094_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	095	0	1	04	01	H2001_095_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	095	0	1	04	01	H2001_095_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	095	0	1	04	01	H2001_095_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2001	095	0	1	04	01	H2001_095_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	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	25						25			25			25		25
H2001	095	0	1	04	01	H2001_095_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H2001	096	0	1	04	01	H2001_096_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	096	0	1	04	01	H2001_096_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	096	0	1	04	01	H2001_096_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	096	0	1	04	01	H2001_096_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	096	0	1	04	01	H2001_096_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H2001	097	0	1	04	01	H2001_097_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	097	0	1	04	01	H2001_097_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	097	0	1	04	01	H2001_097_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2001	097	0	1	04	01	H2001_097_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	097	0	1	04	01	H2001_097_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				390.00	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	25						25			25			25		25
H2001	098	0	1	04	01	H2001_098_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	098	0	1	04	01	H2001_098_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	098	0	1	04	01	H2001_098_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	098	0	1	04	01	H2001_098_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	098	0	1	04	01	H2001_098_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H2001	102	0	1	04	01	H2001_102_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	102	0	1	04	01	H2001_102_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	102	0	1	04	01	H2001_102_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	102	0	1	04	01	H2001_102_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	102	0	1	04	01	H2001_102_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				400.00	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	25						25			25			25		25
H2001	104	0	1	04	01	H2001_104_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	104	0	1	04	01	H2001_104_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	104	0	1	04	01	H2001_104_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	104	0	1	04	01	H2001_104_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	104	0	1	04	01	H2001_104_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H2001	108	0	1	04	01	H2001_108_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	108	0	1	04	01	H2001_108_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	108	0	1	04	01	H2001_108_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	108	0	1	04	01	H2001_108_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	108	0	1	04	01	H2001_108_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H2001	109	0	1	04	01	H2001_109_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	109	0	1	04	01	H2001_109_0	4			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																														
H2001	109	0	1	04	01	H2001_109_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2001	109	0	1	04	01	H2001_109_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				75.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	109	0	1	04	01	H2001_109_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	110	0	1	04	01	H2001_110_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	110	0	1	04	01	H2001_110_0	4			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																														
H2001	110	0	1	04	01	H2001_110_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2001	110	0	1	04	01	H2001_110_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				74.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	110	0	1	04	01	H2001_110_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				389.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2001	115	0	1	04	01	H2001_115_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	115	0	1	04	01	H2001_115_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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	115	0	1	04	01	H2001_115_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				31.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2001	115	0	1	04	01	H2001_115_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				49.00	45																										45						45					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	115	0	1	04	01	H2001_115_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
H2001	116	0	1	04	01	H2001_116_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	116	0	1	04	01	H2001_116_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	116	0	1	04	01	H2001_116_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	116	0	1	04	01	H2001_116_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	116	0	1	04	01	H2001_116_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H2001	117	0	1	04	01	H2001_117_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	117	0	1	04	01	H2001_117_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	117	0	1	04	01	H2001_117_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2001	117	0	1	04	01	H2001_117_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	117	0	1	04	01	H2001_117_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				445.00	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	25						25			25			25		25
H2001	119	0	1	04	01	H2001_119_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	119	0	1	04	01	H2001_119_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	119	0	1	04	01	H2001_119_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				29.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	119	0	1	04	01	H2001_119_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	119	0	1	04	01	H2001_119_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				315.00	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	25						25			25			25		25
H2001	120	0	1	04	01	H2001_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																														
H2001	120	0	1	04	01	H2001_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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	120	0	1	04	01	H2001_120_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	120	0	1	04	01	H2001_120_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	120	0	1	04	01	H2001_120_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H2001	123	0	1	04	01	H2001_123_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	123	0	1	04	01	H2001_123_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	123	0	1	04	01	H2001_123_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	123	0	1	04	01	H2001_123_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	123	0	1	04	01	H2001_123_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				401.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	125	0	1	04	01	H2001_125_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	125	0	1	04	01	H2001_125_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	125	0	1	04	01	H2001_125_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	125	0	1	04	01	H2001_125_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	125	0	1	04	01	H2001_125_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				323.00	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	25						25			25			25		25
H2001	127	0	1	04	01	H2001_127_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	127	0	1	04	01	H2001_127_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	127	0	1	04	01	H2001_127_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	127	0	1	04	01	H2001_127_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	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	25						25			25			25		25
H2001	127	0	1	04	01	H2001_127_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				356.00	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	25						25			25			25		25
H2001	128	0	1	04	01	H2001_128_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	128	0	1	04	01	H2001_128_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	128	0	1	04	01	H2001_128_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	128	0	1	04	01	H2001_128_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	128	0	1	04	01	H2001_128_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H2001	131	0	1	04	01	H2001_131_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	131	0	1	04	01	H2001_131_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	131	0	1	04	01	H2001_131_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2001	131	0	1	04	01	H2001_131_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	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	25						25			25			25		25
H2001	131	0	1	04	01	H2001_131_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H2001	132	0	1	04	01	H2001_132_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	132	0	1	04	01	H2001_132_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	132	0	1	04	01	H2001_132_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	132	0	1	04	01	H2001_132_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	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	25						25			25			25		25
H2001	132	0	1	04	01	H2001_132_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H2001	133	0	1	04	01	H2001_133_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	133	0	1	04	01	H2001_133_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	133	0	1	04	01	H2001_133_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H2001	133	0	1	04	01	H2001_133_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	133	0	1	04	01	H2001_133_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H2001	136	0	1	04	01	H2001_136_0	3			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	3			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	136	0	1	04	01	H2001_136_0	3			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2001	136	0	1	04	01	H2001_136_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	136	0	1	04	01	H2001_136_0	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H2001	137	0	1	04	01	H2001_137_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	137	0	1	04	01	H2001_137_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	137	0	1	04	01	H2001_137_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2001	137	0	1	04	01	H2001_137_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	137	0	1	04	01	H2001_137_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H2001	138	0	1	04	01	H2001_138_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	138	0	1	04	01	H2001_138_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2001	138	0	1	04	01	H2001_138_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				28.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2001	138	0	1	04	01	H2001_138_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				42.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2001	138	0	1	04	01	H2001_138_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				310.00	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	25						25			25			25		25
H2032	001	0	1	04	01	H2032_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								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	25	25	25	25	25	25	25	25	25				25		25
H2032	001	0	1	04	01	H2032_001_0	8			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					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	25	25	25	25	25	25	25	25	25				25		25
H2032	001	0	1	04	01	H2032_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					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	25	25	25	25	25	25	25	25	25				25		25
H2032	001	0	1	04	01	H2032_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											75.31	35	35	35				75.31	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2032	001	0	1	04	01	H2032_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	25	25	25	25	25	25	25	25	25				25		25
H2032	002	0	1	04	01	H2032_002_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					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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H2032	002	0	1	04	01	H2032_002_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											83.11	35	35	35				83.11	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H2032	003	0	1	04	01	H2032_003_0	10			Generic	4	11	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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H2032	003	0	1	04	01	H2032_003_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											78.68	35	35	35				78.68	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	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	25	25	25	25	25	25	25	25	25				25		25
H2032	004	0	1	04	01	H2032_004_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					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	25	25	25	25	25	25	25	25	25				25		25
H2032	004	0	1	04	01	H2032_004_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	25	25	25	25	25	25	25	25	25				25		25
H2032	004	0	1	04	01	H2032_004_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											83.49	35	35	35				83.49	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2032	004	0	1	04	01	H2032_004_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																														
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				32.00	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	19	19	19				19	19	19				19		19
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2041	002	0	1	01	01	H2041_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	0	0	0				0	0	0				0		0
H2041	002	0	1	01	01	H2041_002_0	6			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	25	25	25				25	25	25				25		25
H2041	002	0	1	01	01	H2041_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				39.00	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	21	21	21				21	21	21				21		21
H2041	002	0	1	01	01	H2041_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				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	25	25	25				25	25	25				25		25
H2041	002	0	1	01	01	H2041_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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				32.00	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	19	19	19				19	19	19				19		19
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2041	004	0	1	01	01	H2041_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	0	0	0				0	0	0				0		0
H2041	004	0	1	01	01	H2041_004_0	6			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	25	25	25				25	25	25				25		25
H2041	004	0	1	01	01	H2041_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				39.00	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	21	21	21				21	21	21				21		21
H2041	004	0	1	01	01	H2041_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				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	25	25	25				25	25	25				25		25
H2041	004	0	1	01	01	H2041_004_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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				32.00	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	19	19	19				19	19	19				19		19
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				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	25	25	25				25	25	25				25		25
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	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2041	006	0	1	01	01	H2041_006_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H2041	006	0	1	01	01	H2041_006_0	6			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	25	25	25				25	25	25				25		25
H2041	006	0	1	01	01	H2041_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				39.00	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	21	21	21				21	21	21				21		21
H2041	006	0	1	01	01	H2041_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				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	25	25	25				25	25	25				25		25
H2041	006	0	1	01	01	H2041_006_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	25						25						25		25
H2041	007	0	1	01	01	H2041_007_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2041	007	0	1	01	01	H2041_007_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	007	0	1	01	01	H2041_007_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				46.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	007	0	1	01	01	H2041_007_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				65.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	007	0	1	01	01	H2041_007_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	007	0	1	01	01	H2041_007_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	008	0	1	01	01	H2041_008_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2041	008	0	1	01	01	H2041_008_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	008	0	1	01	01	H2041_008_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				47.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	008	0	1	01	01	H2041_008_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				65.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	008	0	1	01	01	H2041_008_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	008	0	1	01	01	H2041_008_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	009	0	1	01	01	H2041_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	0	0	0				0	0	0				0		0
H2041	009	0	1	01	01	H2041_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	0	0	0				0	0	0				0		0
H2041	009	0	1	01	01	H2041_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				32.00	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	19	19	19				19	19	19				19		19
H2041	009	0	1	01	01	H2041_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				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	25	25	25				25	25	25				25		25
H2041	009	0	1	01	01	H2041_009_0	7			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	25						25						25		25
H2041	010	0	1	01	01	H2041_010_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	0	0	0				0	0	0				0		0
H2041	010	0	1	01	01	H2041_010_0	6			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	25	25	25				25	25	25				25		25
H2041	010	0	1	01	01	H2041_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				39.00	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	21	21	21				21	21	21				21		21
H2041	010	0	1	01	01	H2041_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				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	25	25	25				25	25	25				25		25
H2041	010	0	1	01	01	H2041_010_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	25						25						25		25
H2041	011	0	1	01	01	H2041_011_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2041	011	0	1	01	01	H2041_011_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	011	0	1	01	01	H2041_011_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				45.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	011	0	1	01	01	H2041_011_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				63.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	011	0	1	01	01	H2041_011_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	011	0	1	01	01	H2041_011_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	012	0	1	01	01	H2041_012_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2041	012	0	1	01	01	H2041_012_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2041	012	0	1	01	01	H2041_012_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2041	012	0	1	01	01	H2041_012_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	012	0	1	01	01	H2041_012_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	012	0	1	01	01	H2041_012_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	013	0	1	01	01	H2041_013_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2041	013	0	1	01	01	H2041_013_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2041	013	0	1	01	01	H2041_013_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2041	013	0	1	01	01	H2041_013_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	013	0	1	01	01	H2041_013_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	013	0	1	01	01	H2041_013_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	014	0	1	01	01	H2041_014_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2041	014	0	1	01	01	H2041_014_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2041	014	0	1	01	01	H2041_014_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2041	014	0	1	01	01	H2041_014_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	014	0	1	01	01	H2041_014_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	014	0	1	01	01	H2041_014_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	015	0	1	01	01	H2041_015_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2041	015	0	1	01	01	H2041_015_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2041	015	0	1	01	01	H2041_015_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2041	015	0	1	01	01	H2041_015_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	015	0	1	01	01	H2041_015_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	015	0	1	01	01	H2041_015_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2041	016	0	1	01	01	H2041_016_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2041	016	0	1	01	01	H2041_016_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2041	016	0	1	01	01	H2041_016_0	7			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2041	016	0	1	01	01	H2041_016_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H2041	016	0	1	01	01	H2041_016_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2041	016	0	1	01	01	H2041_016_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2056	003	0	1	02	01	H2056_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																														
H2056	003	0	1	02	01	H2056_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					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																														
H2056	003	0	1	02	01	H2056_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											67.41	25	25	25				92.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2056	003	0	1	02	01	H2056_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											38.28	26	26	26				53.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2056	003	0	1	02	01	H2056_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											652.91	29						729.47	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2056	005	0	1	02	01	H2056_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																														
H2056	005	0	1	02	01	H2056_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																														
H2056	005	0	1	02	01	H2056_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											38.06	21	21	21				51.79	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H2056	005	0	1	02	01	H2056_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											29.86	33	33	33				36.30	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2056	005	0	1	02	01	H2056_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											690.94	33						825.08	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	25			25			25			25			25		25
H2108	022	0	1	01	01	H2108_022_0	7			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	022	0	1	01	01	H2108_022_0	7			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	022	0	1	01	01	H2108_022_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	022	0	1	01	01	H2108_022_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											46.48	50	50	50				50.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	022	0	1	01	01	H2108_022_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											621.39	33						544.58	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	25			25			25			25			25		25
H2108	029	0	1	01	01	H2108_029_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	029	0	1	01	01	H2108_029_0	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	029	0	1	01	01	H2108_029_0	6			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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	029	0	1	01	01	H2108_029_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											51.33	50	50	50				52.66	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	029	0	1	01	01	H2108_029_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											577.44	29						545.53	29												29						29					29			29								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	25			25			25			25			25		25
H2108	029	0	1	01	01	H2108_029_0	6			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	030	0	1	01	01	H2108_030_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	030	0	1	01	01	H2108_030_0	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	030	0	1	01	01	H2108_030_0	6			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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	030	0	1	01	01	H2108_030_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											53.83	50	50	50				54.92	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	030	0	1	01	01	H2108_030_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											449.62	30						514.79	30												30						30					30			30								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	25			25			25			25			25		25
H2108	030	0	1	01	01	H2108_030_0	6			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	036	0	1	01	01	H2108_036_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	036	0	1	01	01	H2108_036_0	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	036	0	1	01	01	H2108_036_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	036	0	1	01	01	H2108_036_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											67.12	50	50	50				62.42	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	036	0	1	01	01	H2108_036_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											596.65	30						529.74	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	25			25			25			25			25		25
H2108	041	0	1	01	01	H2108_041_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	041	0	1	01	01	H2108_041_0	6		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	041	0	1	01	01	H2108_041_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											22.89	23	23	23				25.39	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H2108	041	0	1	01	01	H2108_041_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											47.81	25	25	25				55.70	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	041	0	1	01	01	H2108_041_0	6		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											498.27	25						457.14	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	25			25			25			25			25		25
H2108	042	1	1	01	01	H2108_042_1	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	042	1	1	01	01	H2108_042_1	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	042	1	1	01	01	H2108_042_1	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	042	1	1	01	01	H2108_042_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											58.23	50	50	50				47.99	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	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	042	1	1	01	01	H2108_042_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.22	33						574.62	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	25			25			25			25			25		25
H2108	042	2	1	01	01	H2108_042_2	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2108	042	2	1	01	01	H2108_042_2	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2108	042	2	1	01	01	H2108_042_2	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	042	2	1	01	01	H2108_042_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											58.23	50	50	50				47.99	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	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2108	042	2	1	01	01	H2108_042_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.22	33						574.62	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	25			25			25			25			25		25
H2117	001	0	1	04	01	H2117_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2117	001	0	1	04	01	H2117_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2117	001	0	1	04	01	H2117_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											124.12	25	25	25				124.12	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2117	001	0	1	04	01	H2117_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											65.42	36	36	36				61.79	34	34	34											36	36					34	34			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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2117	001	0	1	04	01	H2117_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2117	001	0	1	04	01	H2117_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2117	002	0	1	04	01	H2117_002_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											89.05	20	20	20				89.05	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H2117	002	0	1	04	01	H2117_002_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											34.72	32	32	32				34.72	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2117	002	0	1	04	01	H2117_002_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	4		N	Preferred Generic	4	01	3	2	1	1	111		10	100		1	30	60	90				2	2			90					10	31	4.00	8.00	12.00																					12.00																	4.00			4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	4.00	8.00	12.00						12.00				4.00		4.00	25	25	25						25				25		25
H2168	001	0	1	01	01	H2168_001_0	4		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	25	25	25						25				25		25
H2168	001	0	1	01	01	H2168_001_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				70.84	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	21	21	21						21				21		21
H2168	001	0	1	01	01	H2168_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				56.32	25	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	25	25	25						25				25		25
H2168	001	0	1	01	01	H2168_001_0	4		N	Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				355.93	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2168	001	0	1	01	01	H2168_001_0	4		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	002	0	1	01	01	H2168_002_0	4		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	25	25	25						25				25		25
H2168	002	0	1	01	01	H2168_002_0	4		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	25	25	25						25				25		25
H2168	002	0	1	01	01	H2168_002_0	4		N	Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				72.93	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	23	23	23						23				23		23
H2168	002	0	1	01	01	H2168_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				65.64	25	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	25	25	25						25				25		25
H2168	002	0	1	01	01	H2168_002_0	4		N	Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				270.37	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2168	002	0	1	01	01	H2168_002_0	4		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	004	0	1	01	01	H2168_004_0	4			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	25	25	25						25				25		25
H2168	004	0	1	01	01	H2168_004_0	4			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	25	25	25						25				25		25
H2168	004	0	1	01	01	H2168_004_0	4			Preferred Brand	4	11	1	1	3	1	111		10	100		1	30	60	90				2	2			90					10	31				96.95	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	23	23	23						23				23		23
H2168	004	0	1	01	01	H2168_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		10	100		1	30	60	90				2	2			90					10	31				74.58	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						105.00				35.00		35.00	25	25	25						25				25		25
H2168	004	0	1	01	01	H2168_004_0	4			Specialty Tier	4	10	1	1	5	1	010		10	000		1	30															10	31				634.36	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2168	004	0	1	01	01	H2168_004_0	4			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	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	001	0	1	02	01	H2172_001_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	001	0	1	02	01	H2172_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					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	001	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	001	0	1	02	01	H2172_001_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H2172	001	0	1	02	01	H2172_001_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																														
H2172	002	0	1	02	01	H2172_002_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	002	0	1	02	01	H2172_002_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	002	0	1	02	01	H2172_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					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	002	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	002	0	1	02	01	H2172_002_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	25	25	25	25	25	25	25	25	25				25		25
H2172	002	0	1	02	01	H2172_002_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																														
H2172	008	0	1	02	01	H2172_008_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	008	0	1	02	01	H2172_008_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	008	0	1	02	01	H2172_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					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	84.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	008	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	008	0	1	02	01	H2172_008_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	25	25	25	25	25	25	25	25	25				25		25
H2172	008	0	1	02	01	H2172_008_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																														
H2172	009	0	1	02	01	H2172_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								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	25	25	25	0	0	0	0	0	0				25		25
H2172	009	0	1	02	01	H2172_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	009	0	1	02	01	H2172_009_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	009	0	1	02	01	H2172_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								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	009	0	1	02	01	H2172_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												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	25	25	25	25	25	25	25	25	25				25		25
H2172	009	0	1	02	01	H2172_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																														
H2172	010	0	1	02	01	H2172_010_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	010	0	1	02	01	H2172_010_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	010	0	1	02	01	H2172_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	010	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	010	0	1	02	01	H2172_010_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	25	25	25	25	25	25	25	25	25				25		25
H2172	010	0	1	02	01	H2172_010_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																														
H2172	013	0	1	02	01	H2172_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								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	25	25	25	0	0	0	0	0	0				25		25
H2172	013	0	1	02	01	H2172_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	013	0	1	02	01	H2172_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	013	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	013	0	1	02	01	H2172_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												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	25	25	25	25	25	25	25	25	25				25		25
H2172	013	0	1	02	01	H2172_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																														
H2172	014	0	1	02	01	H2172_014_0	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	014	0	1	02	01	H2172_014_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	014	0	1	02	01	H2172_014_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	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	014	0	1	02	01	H2172_014_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	014	0	1	02	01	H2172_014_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												28	28	28					28	28	28				28	28	28															28			28								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	25	25	25	25	25	25	25	25	25				25		25
H2172	014	0	1	02	01	H2172_014_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																														
H2172	016	0	1	01	01	H2172_016_0	4		N	Preferred Generic	4	11	1	1	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											4.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	016	0	1	01	01	H2172_016_0	4		N	Generic	4	11	1	1	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											10.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	016	0	1	01	01	H2172_016_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											100.00	25	25	25				11.00	5	5	5				5	5	5															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	016	0	1	01	01	H2172_016_0	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											47.00	25	25	25				66.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	016	0	1	01	01	H2172_016_0	4		N	Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											350.00	25	25	25				359.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	016	0	1	01	01	H2172_016_0	4		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	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2172	017	0	1	01	01	H2172_017_0	4		N	Preferred Generic	4	11	1	1	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											3.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	017	0	1	01	01	H2172_017_0	4		N	Generic	4	11	1	1	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											9.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	017	0	1	01	01	H2172_017_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											86.00	25	25	25				21.00	10	10	10				10	10	10															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	017	0	1	01	01	H2172_017_0	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	25	25	25				65.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	017	0	1	01	01	H2172_017_0	4		N	Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											329.00	25	25	25				376.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	017	0	1	01	01	H2172_017_0	4		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	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2172	018	0	1	01	01	H2172_018_0	4		N	Preferred Generic	4	11	1	1	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											4.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	018	0	1	01	01	H2172_018_0	4		N	Generic	4	11	1	1	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											10.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	018	0	1	01	01	H2172_018_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											100.00	25	25	25				11.00	5	5	5				5	5	5															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	018	0	1	01	01	H2172_018_0	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											47.00	25	25	25				66.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	018	0	1	01	01	H2172_018_0	4		N	Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											350.00	25	25	25				360.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	018	0	1	01	01	H2172_018_0	4		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	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2172	019	0	1	01	01	H2172_019_0	4		N	Preferred Generic	4	11	1	1	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											3.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	019	0	1	01	01	H2172_019_0	4		N	Generic	4	11	1	1	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											9.00	25	25	25				0.00	0	0	0				0	0	0															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	019	0	1	01	01	H2172_019_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											86.00	25	25	25				11.00	5	5	5				5	5	5															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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	019	0	1	01	01	H2172_019_0	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	25	25	25				66.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	019	0	1	01	01	H2172_019_0	4		N	Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											330.00	25	25	25				382.00	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	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H2172	019	0	1	01	01	H2172_019_0	4		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	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2172	020	0	1	02	01	H2172_020_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	020	0	1	02	01	H2172_020_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	020	0	1	02	01	H2172_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	020	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	020	0	1	02	01	H2172_020_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	25	25	25	25	25	25	25	25	25				25		25
H2172	020	0	1	02	01	H2172_020_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																														
H2172	021	0	1	02	01	H2172_021_0	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	021	0	1	02	01	H2172_021_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	021	0	1	02	01	H2172_021_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	021	0	1	02	01	H2172_021_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	021	0	1	02	01	H2172_021_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H2172	021	0	1	02	01	H2172_021_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																														
H2172	022	0	1	02	01	H2172_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								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	25	25	25	0	0	0	0	0	0				25		25
H2172	022	0	1	02	01	H2172_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					9.00	18.00	27.00					9.00	0.00	0.00																20.00				20.00			0.67	0.30	0.30			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	0.00				20.00		20.00	25	25	25	0	0	0	0	0	0				25		25
H2172	022	0	1	02	01	H2172_022_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	022	0	1	02	01	H2172_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								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	022	0	1	02	01	H2172_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												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	25	25	25	25	25	25	25	25	25				25		25
H2172	022	0	1	02	01	H2172_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																														
H2172	023	0	1	02	01	H2172_023_0	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	023	0	1	02	01	H2172_023_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	023	0	1	02	01	H2172_023_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	023	0	1	02	01	H2172_023_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	023	0	1	02	01	H2172_023_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H2172	023	0	1	02	01	H2172_023_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																														
H2172	024	0	1	02	01	H2172_024_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	024	0	1	02	01	H2172_024_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					12.00	24.00	36.00					12.00	0.00	0.00																20.00				20.00			0.67	0.40	0.40			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	12.00	24.00	36.00	12.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	024	0	1	02	01	H2172_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	024	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	024	0	1	02	01	H2172_024_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	25	25	25	25	25	25	25	25	25				25		25
H2172	024	0	1	02	01	H2172_024_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																														
H2172	025	0	1	01	01	H2172_025_0	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	025	0	1	01	01	H2172_025_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					13.00	26.00	39.00					13.00	0.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	13.00	26.00	39.00	13.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	025	0	1	01	01	H2172_025_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	025	0	1	01	01	H2172_025_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					90.00	180.00	270.00					90.00	180.00	180.00																100.00				100.00			3.33	3.00	3.00			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	025	0	1	01	01	H2172_025_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												28	28	28					28	28	28				28	28	28															28			28								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	25	25	25	25	25	25	25	25	25				25		25
H2172	025	0	1	01	01	H2172_025_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																														
H2172	026	0	1	01	01	H2172_026_0	5			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	25	25	25	0	0	0	0	0	0				25		25
H2172	026	0	1	01	01	H2172_026_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					13.00	26.00	39.00					13.00	0.00	0.00																20.00				20.00			0.67	0.43	0.43			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	13.00	26.00	39.00	13.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H2172	026	0	1	01	01	H2172_026_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					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	026	0	1	01	01	H2172_026_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	026	0	1	01	01	H2172_026_0	5			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												28	28	28					28	28	28				28	28	28															28			28								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	25	25	25	25	25	25	25	25	25				25		25
H2172	026	0	1	01	01	H2172_026_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																														
H2172	027	0	1	02	01	H2172_027_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					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	25	25	25	0	0	0	0	0	0				25		25
H2172	027	0	1	02	01	H2172_027_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					15.00	30.00	45.00					15.00	0.00	0.00																20.00				20.00			0.67	0.50	0.50			0.65	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	25	25	25	25	25	25	25	0	0				25		25
H2172	027	0	1	02	01	H2172_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	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	027	0	1	02	01	H2172_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	200.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2172	027	0	1	02	01	H2172_027_0	4			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31												28	28	28					28	28	28				28	28	28															28			28								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	25	25	25	25	25	25	25	25	25				25		25
H2172	027	0	1	02	01	H2172_027_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																														
H2174	001	0	1	02	01	H2174_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	001	0	1	02	01	H2174_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	001	0	1	02	01	H2174_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											106.59	25	25	25				106.59	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	001	0	1	02	01	H2174_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	001	0	1	02	01	H2174_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	001	0	1	02	01	H2174_001_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	012	0	1	02	01	H2174_012_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	012	0	1	02	01	H2174_012_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	012	0	1	02	01	H2174_012_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.69	25	25	25				100.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	012	0	1	02	01	H2174_012_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	012	0	1	02	01	H2174_012_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	012	0	1	02	01	H2174_012_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					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																														
H2174	013	0	1	02	01	H2174_013_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	013	0	1	02	01	H2174_013_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	013	0	1	02	01	H2174_013_0	8		N	Preferred Brand	3	11	1	2	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					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	105.00		70.00	105.00		70.00	94.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	013	0	1	02	01	H2174_013_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.04	43	43	43				91.04	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2174	013	0	1	02	01	H2174_013_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2174	013	0	1	02	01	H2174_013_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2185	003	0	1	02	01	H2185_003_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 Drug, Specialty Tier																														
H2185	003	0	1	02	01	H2185_003_0	5			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 Drug, Specialty Tier																														
H2185	003	0	1	02	01	H2185_003_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2185	003	0	1	02	01	H2185_003_0	5			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2185	003	0	1	02	01	H2185_003_0	5			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 Drug, Specialty Tier																														
H2224	001	0	1	01	01	H2224_001_0	11		N	Single Tier	4	11	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								Single Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2230	002	0	1	04	01	H2230_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								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	25	25	25	0	0	0	0	0	0				25		25
H2230	002	0	1	04	01	H2230_002_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					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	25	25	25	25	25	25	25	25	25				25		25
H2230	002	0	1	04	01	H2230_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					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	25	25	25	25	25	25	25	25	25				25		25
H2230	002	0	1	04	01	H2230_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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	25	25	25	25	25	25	25	25	25				25		25
H2230	002	0	1	04	01	H2230_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2230	018	1	1	04	01	H2230_018_1	6			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	25	25	25	0	0	0	0	0	0				25		25
H2230	018	1	1	04	01	H2230_018_1	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	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	25	25	25	25	25	25	25	25	25				25		25
H2230	018	1	1	04	01	H2230_018_1	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											79.13	20	20	20				78.35	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	20	20	20	20	20	20	20	20	20				20		20
H2230	018	1	1	04	01	H2230_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											71.12	39	39	39				54.29	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2230	018	1	1	04	01	H2230_018_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2230	018	2	1	04	01	H2230_018_2	6			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	25	25	25	0	0	0	0	0	0				25		25
H2230	018	2	1	04	01	H2230_018_2	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	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	25	25	25	25	25	25	25	25	25				25		25
H2230	018	2	1	04	01	H2230_018_2	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											79.13	20	20	20				78.35	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	20	20	20	20	20	20	20	20	20				20		20
H2230	018	2	1	04	01	H2230_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											71.12	39	39	39				54.29	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2230	018	2	1	04	01	H2230_018_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2230	019	0	1	04	01	H2230_019_0	6			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	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	25	25	25	0	0	0	0	0	0				25		25
H2230	019	0	1	04	01	H2230_019_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								20.00	40.00	60.00					10.00	20.00	30.00					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	25	25	25	25	25	25	25	25	25				25		25
H2230	019	0	1	04	01	H2230_019_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											116.56	25	25	25				117.66	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2230	019	0	1	04	01	H2230_019_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											63.54	25	25	25				43.43	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H2230	019	0	1	04	01	H2230_019_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	25			25			25						25		25
H2235	001	0	1	01	01	H2235_001_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2235	001	0	1	01	01	H2235_001_0	8			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																					30.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00						30.00				10.00		10.00	25	25	25						25				25		25
H2235	001	0	1	01	01	H2235_001_0	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	141.00																					121.00																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	25	25	25						25				25		25
H2235	001	0	1	01	01	H2235_001_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				99.11	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	25	25	25						25				25		25
H2235	001	0	1	01	01	H2235_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				498.94	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2235	002	0	1	01	01	H2235_002_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2235	002	0	1	01	01	H2235_002_0	8			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																					30.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00						30.00				10.00		10.00	25	25	25						25				25		25
H2235	002	0	1	01	01	H2235_002_0	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	141.00																					121.00																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	25	25	25						25				25		25
H2235	002	0	1	01	01	H2235_002_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				91.94	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	25	25	25						25				25		25
H2235	002	0	1	01	01	H2235_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				677.79	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2235	003	0	1	01	01	H2235_003_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2235	003	0	1	01	01	H2235_003_0	8			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																					30.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00						30.00				10.00		10.00	25	25	25						25				25		25
H2235	003	0	1	01	01	H2235_003_0	8			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	47.00	94.00	141.00																					121.00																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	25	25	25						25				25		25
H2235	003	0	1	01	01	H2235_003_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				93.18	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	25	25	25						25				25		25
H2235	003	0	1	01	01	H2235_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				442.27	32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	001	0	1	02	01	H2247_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2247	001	0	1	02	01	H2247_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2247	001	0	1	02	01	H2247_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H2247	001	0	1	02	01	H2247_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	001	0	1	02	01	H2247_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	003	0	1	02	01	H2247_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2247	003	0	1	02	01	H2247_003_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2247	003	0	1	02	01	H2247_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H2247	003	0	1	02	01	H2247_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	003	0	1	02	01	H2247_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	004	0	1	01	01	H2247_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2247	004	0	1	01	01	H2247_004_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2247	004	0	1	01	01	H2247_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H2247	004	0	1	01	01	H2247_004_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	004	0	1	01	01	H2247_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	005	0	1	01	01	H2247_005_0	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2247	005	0	1	01	01	H2247_005_0	5		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2247	005	0	1	01	01	H2247_005_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H2247	005	0	1	01	01	H2247_005_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2247	005	0	1	01	01	H2247_005_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2256	001	1	1	01	01	H2256_001_1	9			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	25	25	25				25	25	25				25		25
H2256	001	1	1	01	01	H2256_001_1	9			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	25	25	25				25	25	25				25		25
H2256	001	1	1	01	01	H2256_001_1	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				36.06	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	001	1	1	01	01	H2256_001_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.37	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	001	1	1	01	01	H2256_001_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	001	1	1	01	01	H2256_001_1	9			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	8			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	25	25	25				25	25	25				25		25
H2256	001	2	1	01	01	H2256_001_2	8			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	25	25	25				25	25	25				25		25
H2256	001	2	1	01	01	H2256_001_2	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				36.06	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	001	2	1	01	01	H2256_001_2	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.37	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	001	2	1	01	01	H2256_001_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	001	2	1	01	01	H2256_001_2	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	001	6	1	01	01	H2256_001_6	9			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	25	25	25				25	25	25				25		25
H2256	001	6	1	01	01	H2256_001_6	9			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	25	25	25				25	25	25				25		25
H2256	001	6	1	01	01	H2256_001_6	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				36.06	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	001	6	1	01	01	H2256_001_6	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.37	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	001	6	1	01	01	H2256_001_6	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, Vaccines																														
H2256	001	6	1	01	01	H2256_001_6	9			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	9			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	25	25	25				25	25	25				25		25
H2256	015	1	1	01	01	H2256_015_1	9			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	25	25	25				25	25	25				25		25
H2256	015	1	1	01	01	H2256_015_1	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				34.74	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	015	1	1	01	01	H2256_015_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.75	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	015	1	1	01	01	H2256_015_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	015	1	1	01	01	H2256_015_1	9			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	9			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	25	25	25				25	25	25				25		25
H2256	015	2	1	01	01	H2256_015_2	9			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	25	25	25				25	25	25				25		25
H2256	015	2	1	01	01	H2256_015_2	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				34.74	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	015	2	1	01	01	H2256_015_2	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.75	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	015	2	1	01	01	H2256_015_2	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	015	2	1	01	01	H2256_015_2	9			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	9			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	25	25	25				25	25	25				25		25
H2256	015	6	1	01	01	H2256_015_6	9			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	25	25	25				25	25	25				25		25
H2256	015	6	1	01	01	H2256_015_6	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				34.74	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	015	6	1	01	01	H2256_015_6	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.75	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	015	6	1	01	01	H2256_015_6	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, Vaccines																														
H2256	015	6	1	01	01	H2256_015_6	9			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	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	018	1	1	01	01	H2256_018_1	9			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	25	25	25	25	25	25	25	25	25				25		25
H2256	018	1	1	01	01	H2256_018_1	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											35.34	20	20	20				34.66	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	018	1	1	01	01	H2256_018_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											75.41	40	40	40				73.89	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	018	1	1	01	01	H2256_018_1	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	018	1	1	01	01	H2256_018_1	9			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	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	25	25	25	0	0	0	0	0	0				25		0
H2256	018	7	1	01	01	H2256_018_7	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00	25	25	25	25	25	25	25	25	25				25		25
H2256	018	7	1	01	01	H2256_018_7	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											35.34	20	20	20				34.66	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	018	7	1	01	01	H2256_018_7	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											75.41	40	40	40				73.89	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	018	7	1	01	01	H2256_018_7	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																														
H2256	018	7	1	01	01	H2256_018_7	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																														
H2256	018	8	1	01	01	H2256_018_8	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	25	25	25	0	0	0	0	0	0				25		0
H2256	018	8	1	01	01	H2256_018_8	8			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								19.00	38.00	57.00					4.00	8.00	12.00					4.00	8.00	8.00																19.00				4.00			0.63	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	19.00	38.00	57.00	4.00	8.00	12.00	4.00	8.00	8.00				19.00		4.00	25	25	25	25	25	25	25	25	25				25		25
H2256	018	8	1	01	01	H2256_018_8	8			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											35.34	20	20	20				34.66	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	018	8	1	01	01	H2256_018_8	8			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											75.41	40	40	40				73.89	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	018	8	1	01	01	H2256_018_8	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																														
H2256	018	8	1	01	01	H2256_018_8	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																														
H2256	026	1	1	01	01	H2256_026_1	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	026	1	1	01	01	H2256_026_1	9			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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	1	1	01	01	H2256_026_1	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											33.62	20	20	20				34.07	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	026	1	1	01	01	H2256_026_1	9			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	40	40	40				65.04	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	1	1	01	01	H2256_026_1	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	026	1	1	01	01	H2256_026_1	9			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	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	026	2	1	01	01	H2256_026_2	9			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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	2	1	01	01	H2256_026_2	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											33.62	20	20	20				34.07	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	026	2	1	01	01	H2256_026_2	9			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	40	40	40				65.04	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	2	1	01	01	H2256_026_2	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	026	2	1	01	01	H2256_026_2	9			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	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	026	3	1	01	01	H2256_026_3	9			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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	3	1	01	01	H2256_026_3	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											33.62	20	20	20				34.07	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	026	3	1	01	01	H2256_026_3	9			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	40	40	40				65.04	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	026	3	1	01	01	H2256_026_3	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	026	3	1	01	01	H2256_026_3	9			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	9			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	25	25	25				25	25	25				25		25
H2256	033	0	1	01	01	H2256_033_0	9			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	25	25	25				25	25	25				25		25
H2256	033	0	1	01	01	H2256_033_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				33.74	20	20	20																		20	20	20															20			20								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	20	20	20				20	20	20				20		20
H2256	033	0	1	01	01	H2256_033_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				53.67	40	40	40																		40	40	40															40			40								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	25	25	25				25	25	25				25		25
H2256	033	0	1	01	01	H2256_033_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, Vaccines																														
H2256	033	0	1	01	01	H2256_033_0	9			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	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	034	0	1	01	01	H2256_034_0	9			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	25	25	25	25	25	25	25	25	25				25		25
H2256	034	0	1	01	01	H2256_034_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											34.90	20	20	20				34.02	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	034	0	1	01	01	H2256_034_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											74.45	40	40	40				76.29	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	034	0	1	01	01	H2256_034_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	034	0	1	01	01	H2256_034_0	9			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	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	036	0	1	01	01	H2256_036_0	9			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	25	25	25	0	0	0	0	0	0				25		0
H2256	036	0	1	01	01	H2256_036_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											32.90	20	20	20				33.60	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	036	0	1	01	01	H2256_036_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											60.98	40	40	40				63.69	40	40	40				40	40	40															40			40								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	25	25	25	25	25	25	25	25	25				25		25
H2256	036	0	1	01	01	H2256_036_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H2256	036	0	1	01	01	H2256_036_0	9			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	9			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H2256	046	0	1	01	01	H2256_046_0	9			Generic	4	01	3	2	2	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					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H2256	046	0	1	01	01	H2256_046_0	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.75	20	20	20				49.57	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H2256	046	0	1	01	01	H2256_046_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											65.80	25	25	25				64.02	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	25	25	25	25	25	25	25	25	25				25		25
H2256	046	0	1	01	01	H2256_046_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, Vaccines																														
H2256	046	0	1	01	01	H2256_046_0	9			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	7			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	25	25	25	0	0	0	0	0	0				25		25
H2261	005	0	1	01	01	H2261_005_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	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	25	25	25	25	25	25	25	25	25				25		25
H2261	005	0	1	01	01	H2261_005_0	7			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	005	0	1	01	01	H2261_005_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	005	0	1	01	01	H2261_005_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	25			25			25						25		25
H2261	022	1	1	01	01	H2261_022_1	6			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	25	25	25	0	0	0	0	0	0				25		25
H2261	022	1	1	01	01	H2261_022_1	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	1	1	01	01	H2261_022_1	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	1	1	01	01	H2261_022_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	1	1	01	01	H2261_022_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2261	022	2	1	01	01	H2261_022_2	6			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	25	25	25	0	0	0	0	0	0				25		25
H2261	022	2	1	01	01	H2261_022_2	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	2	1	01	01	H2261_022_2	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	2	1	01	01	H2261_022_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	022	2	1	01	01	H2261_022_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												28							28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2261	023	1	1	02	01	H2261_023_1	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	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	25	25	25	0	0	0	0	0	0				25		25
H2261	023	1	1	02	01	H2261_023_1	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	1	1	02	01	H2261_023_1	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	1	1	02	01	H2261_023_1	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	1	1	02	01	H2261_023_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2261	023	2	1	02	01	H2261_023_2	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	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	25	25	25	0	0	0	0	0	0				25		25
H2261	023	2	1	02	01	H2261_023_2	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								10.00	20.00	30.00					5.00	10.00	15.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	2	1	02	01	H2261_023_2	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					42.00	84.00	126.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	2	1	02	01	H2261_023_2	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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	25	25	25	25	25	25	25	25	25				25		25
H2261	023	2	1	02	01	H2261_023_2	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2261	024	0	1	02	01	H2261_024_0	6			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	25	25	25	0	0	0	0	0	0				25		25
H2261	024	0	1	02	01	H2261_024_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								15.00	30.00	45.00					5.00	10.00	15.00					5.00	10.00	10.00																15.00				15.00			0.50	0.17	0.17			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	5.00	10.00	15.00	5.00	10.00	10.00				15.00		15.00	25	25	25	25	25	25	25	25	25				25		25
H2261	024	0	1	02	01	H2261_024_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											73.91	20	20	20				77.36	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	20	20	20	20	20	20	20	20	20				20		20
H2261	024	0	1	02	01	H2261_024_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											62.32	40	40	40				41.36	40	40	40				40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2261	024	0	1	02	01	H2261_024_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H2272	001	0	1	02	01	H2272_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2272	001	0	1	02	01	H2272_001_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2272	001	0	1	02	01	H2272_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H2272	001	0	1	02	01	H2272_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2272	001	0	1	02	01	H2272_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				384.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2272	003	0	1	02	01	H2272_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2272	003	0	1	02	01	H2272_003_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2272	003	0	1	02	01	H2272_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2272	003	0	1	02	01	H2272_003_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2272	003	0	1	02	01	H2272_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2293	001	0	1	04	01	H2293_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																														
H2293	001	0	1	04	01	H2293_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																														
H2293	001	0	1	04	01	H2293_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											65.18	22	22	22				84.21	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2293	001	0	1	04	01	H2293_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											40.32	25	25	25				49.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	001	0	1	04	01	H2293_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											558.50	25						611.80	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	25			25			25			25			25		25
H2293	002	0	1	04	01	H2293_002_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	002	0	1	04	01	H2293_002_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	002	0	1	04	01	H2293_002_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				73.84	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	22	22	22				22	22	22				22		22
H2293	002	0	1	04	01	H2293_002_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2293	002	0	1	04	01	H2293_002_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.12	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2293	004	0	1	04	01	H2293_004_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	004	0	1	04	01	H2293_004_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	004	0	1	04	01	H2293_004_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				75.16	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	22	22	22				22	22	22				22		22
H2293	004	0	1	04	01	H2293_004_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				41.50	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2293	004	0	1	04	01	H2293_004_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				521.81	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											71.03	24	24	24				105.36	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.97	25	25	25				52.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											649.23	25						863.14	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	25			25			25			25			25		25
H2293	014	0	1	04	01	H2293_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																														
H2293	014	0	1	04	01	H2293_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																														
H2293	014	0	1	04	01	H2293_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											70.11	24	24	24				97.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2293	014	0	1	04	01	H2293_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											37.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	014	0	1	04	01	H2293_014_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											567.37	25						567.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2293	016	0	1	04	01	H2293_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																														
H2293	016	0	1	04	01	H2293_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																														
H2293	016	0	1	04	01	H2293_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											79.69	24	24	24				102.64	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2293	016	0	1	04	01	H2293_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											47.94	25	25	25				44.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	016	0	1	04	01	H2293_016_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											522.09	25						526.75	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	25			25			25			25			25		25
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											82.14	24	24	24				108.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.07	25	25	25				45.87	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											538.65	25						541.79	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	25			25			25			25			25		25
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											74.54	24	24	24				99.72	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											585.09	25						677.17	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	25			25			25			25			25		25
H2293	021	0	1	04	01	H2293_021_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	021	0	1	04	01	H2293_021_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2293	021	0	1	04	01	H2293_021_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.05	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	22	22	22				22	22	22				22		22
H2293	021	0	1	04	01	H2293_021_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2293	021	0	1	04	01	H2293_021_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				490.62	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2293	023	0	1	04	01	H2293_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																														
H2293	023	0	1	04	01	H2293_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																														
H2293	023	0	1	04	01	H2293_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											67.15	22	22	22				87.82	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2293	023	0	1	04	01	H2293_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											39.52	25	25	25				43.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	023	0	1	04	01	H2293_023_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											546.07	25						639.18	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	25			25			25			25			25		25
H2293	025	0	1	04	01	H2293_025_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	025	0	1	04	01	H2293_025_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	025	0	1	04	01	H2293_025_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.12	24	24	24				92.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2293	025	0	1	04	01	H2293_025_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				44.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	025	0	1	04	01	H2293_025_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											542.56	25						688.34	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	25			25			25			25			25		25
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											67.76	24	24	24				98.27	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.81	25	25	25				49.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											634.78	25						782.66	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	25			25			25			25			25		25
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											70.80	24	24	24				93.29	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.52	25	25	25				45.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											628.29	25						905.21	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	25			25			25			25			25		25
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											68.36	24	24	24				91.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.25	25	25	25				45.62	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											594.21	25						684.22	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	25			25			25			25			25		25
H2293	033	0	1	04	01	H2293_033_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.88	22	22	22				85.14	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2293	033	0	1	04	01	H2293_033_0	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				51.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	033	0	1	04	01	H2293_033_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.20	25						706.21	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	25			25			25			25			25		25
H2293	035	0	1	04	01	H2293_035_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	035	0	1	04	01	H2293_035_0	2			Generic	4	01	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	035	0	1	04	01	H2293_035_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.85	22	22	22				93.72	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2293	035	0	1	04	01	H2293_035_0	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				49.41	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2293	035	0	1	04	01	H2293_035_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											536.24	25						797.20	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	25			25			25			25			25		25
H2320	022	1	1	02	01	H2320_022_1	6			Preferred Generic	4	01	1	2	1	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	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	022	1	1	02	01	H2320_022_1	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					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																														
H2320	022	1	1	02	01	H2320_022_1	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.89	25	25	25				65.71	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.99	30	30	30				14.68	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	022	2	1	02	01	H2320_022_2	6			Preferred Generic	4	01	1	2	1	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	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	022	2	1	02	01	H2320_022_2	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					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																														
H2320	022	2	1	02	01	H2320_022_2	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.89	25	25	25				65.71	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.99	30	30	30				14.68	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	022	3	1	02	01	H2320_022_3	6			Preferred Generic	4	01	1	2	1	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	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	022	3	1	02	01	H2320_022_3	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					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																														
H2320	022	3	1	02	01	H2320_022_3	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.89	25	25	25				65.71	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
H2320	022	3	1	02	01	H2320_022_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											18.99	30	30	30				14.68	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	022	3	1	02	01	H2320_022_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	022	4	1	02	01	H2320_022_4	6			Preferred Generic	4	01	1	2	1	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	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	022	4	1	02	01	H2320_022_4	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					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																														
H2320	022	4	1	02	01	H2320_022_4	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.89	25	25	25				65.71	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
H2320	022	4	1	02	01	H2320_022_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											18.99	30	30	30				14.68	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	022	4	1	02	01	H2320_022_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	022	5	1	02	01	H2320_022_5	6			Preferred Generic	4	01	1	2	1	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	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	022	5	1	02	01	H2320_022_5	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					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																														
H2320	022	5	1	02	01	H2320_022_5	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											69.89	25	25	25				65.71	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.99	30	30	30				14.68	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	028	1	1	02	01	H2320_028_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	028	1	1	02	01	H2320_028_1	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.30	25	25	25				56.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	1	1	02	01	H2320_028_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											15.82	38	38	38				12.82	33	33	33										38	38	38				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	1	1	02	01	H2320_028_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	028	2	1	02	01	H2320_028_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	028	2	1	02	01	H2320_028_2	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.30	25	25	25				56.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	2	1	02	01	H2320_028_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											15.82	38	38	38				12.82	33	33	33										38	38	38				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	2	1	02	01	H2320_028_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	028	3	1	02	01	H2320_028_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	028	3	1	02	01	H2320_028_3	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.30	25	25	25				56.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	3	1	02	01	H2320_028_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											15.82	38	38	38				12.82	33	33	33										38	38	38				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	3	1	02	01	H2320_028_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	028	4	1	02	01	H2320_028_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	028	4	1	02	01	H2320_028_4	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.30	25	25	25				56.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	4	1	02	01	H2320_028_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											15.82	38	38	38				12.82	33	33	33										38	38	38				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	4	1	02	01	H2320_028_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	028	5	1	02	01	H2320_028_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	0.00											6.00	12.00	18.00				1.00	2.00	0.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	028	5	1	02	01	H2320_028_5	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.30	25	25	25				56.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	5	1	02	01	H2320_028_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											15.82	38	38	38				12.82	33	33	33										38	38	38				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	028	5	1	02	01	H2320_028_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	029	1	1	02	01	H2320_029_1	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.45	25	25	25				54.39	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.50	40	40	40				15.99	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	029	1	1	02	01	H2320_029_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	029	2	1	02	01	H2320_029_2	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.45	25	25	25				54.39	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.50	40	40	40				15.99	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	029	2	1	02	01	H2320_029_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	029	3	1	02	01	H2320_029_3	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.45	25	25	25				54.39	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.50	40	40	40				15.99	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	029	3	1	02	01	H2320_029_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	029	4	1	02	01	H2320_029_4	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.45	25	25	25				54.39	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.50	40	40	40				15.99	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	029	4	1	02	01	H2320_029_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	029	5	1	02	01	H2320_029_5	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.45	25	25	25				54.39	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.50	40	40	40				15.99	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	029	5	1	02	01	H2320_029_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	031	0	1	02	01	H2320_031_0	6			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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2320	031	0	1	02	01	H2320_031_0	6			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					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																														
H2320	031	0	1	02	01	H2320_031_0	6			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											68.69	25	25	25				69.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	031	0	1	02	01	H2320_031_0	6			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											26.92	40	40	40				17.53	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	031	0	1	02	01	H2320_031_0	6			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		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	25			25			25			25			25		25
H2320	032	1	1	02	01	H2320_032_1	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	032	1	1	02	01	H2320_032_1	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	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	032	1	1	02	01	H2320_032_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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	1	1	02	01	H2320_032_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											18.21	25	25	25				13.77	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	1	1	02	01	H2320_032_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	032	2	1	02	01	H2320_032_2	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	032	2	1	02	01	H2320_032_2	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	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	032	2	1	02	01	H2320_032_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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	2	1	02	01	H2320_032_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											18.21	25	25	25				13.77	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	2	1	02	01	H2320_032_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2320	032	5	1	02	01	H2320_032_5	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	032	5	1	02	01	H2320_032_5	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								13.00	26.00	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	032	5	1	02	01	H2320_032_5	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	5	1	02	01	H2320_032_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											18.21	25	25	25				13.77	25	25	25										25	25	25				25	25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2320	032	5	1	02	01	H2320_032_5	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H2322	008	0	1	04	01	H2322_008_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	008	0	1	04	01	H2322_008_0	7			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					9.00	18.00	27.00											15.00	30.00	45.00				9.00	18.00	0.00				15.00				9.00			0.50	0.30		0.50	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	9.00	18.00	27.00	15.00	30.00	45.00	9.00	18.00	0.00	15.00		9.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2322	008	0	1	04	01	H2322_008_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.75	17	17	17				43.30	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
H2322	008	0	1	04	01	H2322_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		31											37.71	39	39	39				33.99	37	37	37										39	39	39				37	37	37			39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2322	008	0	1	04	01	H2322_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
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											61.02	17	17	17				56.08	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
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											53.22	39	39	39				53.08	37	37	37										39	39	39				37	37	37			39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												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	25			25			25			25			25		25
H2322	016	0	1	04	01	H2322_016_0	6			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	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2322	016	0	1	04	01	H2322_016_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											61.18	17	17	17				56.43	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
H2322	016	0	1	04	01	H2322_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		31											54.70	39	39	39				54.82	37	37	37										39	39	39				37	37	37			39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2322	016	0	1	04	01	H2322_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2322	017	0	1	04	01	H2322_017_0	7			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.33	20	20	20				69.04	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	20	20	20	18	18	18	20	20	20	18	18	18	20		18
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											65.97	42	42	42				72.39	40	40	40										42	42	42				40	40	40			42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
H2354	015	0	1	01	01	H2354_015_0	6			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	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2354	015	0	1	01	01	H2354_015_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.60	17	17	17				52.63	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
H2354	015	0	1	01	01	H2354_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		31											55.33	42	42	42				52.37	40	40	40										42	42	42				40	40	40			42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2354	015	0	1	01	01	H2354_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
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											40.34	17	17	17				42.27	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
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											34.83	41	41	41				32.83	39	39	39										41	41	41				39	39	39			41			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
H2354	021	0	1	02	01	H2354_021_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	021	0	1	02	01	H2354_021_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2354	021	0	1	02	01	H2354_021_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.25	17	17	17				43.20	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
H2354	021	0	1	02	01	H2354_021_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											37.68	42	42	42				35.53	40	40	40										42	42	42				40	40	40			42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2354	021	0	1	02	01	H2354_021_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	25			25			25			25			25		25
H2354	028	0	1	01	01	H2354_028_0	6			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	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2354	028	0	1	01	01	H2354_028_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.98	17	17	17				56.64	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
H2354	028	0	1	01	01	H2354_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		31											56.09	40	40	40				53.03	38	38	38										40	40	40				38	38	38			40			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2354	028	0	1	01	01	H2354_028_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								15.00	30.00	45.00					9.00	18.00	27.00											15.00	30.00	45.00				9.00	18.00	0.00				15.00				9.00			0.50	0.30		0.50	0.30	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	9.00	18.00	27.00	15.00	30.00	45.00	9.00	18.00	0.00	15.00		9.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
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											56.08	17	17	17				50.64	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	17	17	17	15	15	15	17	17	17	15	15	15	17		15
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											57.47	39	39	39				49.88	37	37	37										39	39	39				37	37	37			39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
H2385	001	0	1	04	01	H2385_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2385	001	0	1	04	01	H2385_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2385	001	0	1	04	01	H2385_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2385	001	0	1	04	01	H2385_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	001	0	1	04	01	H2385_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				340.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	002	0	1	04	01	H2385_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2385	002	0	1	04	01	H2385_002_0	4		N	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																														
H2385	002	0	1	04	01	H2385_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				60.00	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	25		25						25				25		25
H2385	002	0	1	04	01	H2385_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	002	0	1	04	01	H2385_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				354.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	003	0	1	04	01	H2385_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2385	003	0	1	04	01	H2385_003_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2385	003	0	1	04	01	H2385_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H2385	003	0	1	04	01	H2385_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	003	0	1	04	01	H2385_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				352.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	004	0	1	04	01	H2385_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2385	004	0	1	04	01	H2385_004_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2385	004	0	1	04	01	H2385_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2385	004	0	1	04	01	H2385_004_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2385	004	0	1	04	01	H2385_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	008	0	1	04	01	H2406_008_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	008	0	1	04	01	H2406_008_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	008	0	1	04	01	H2406_008_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	008	0	1	04	01	H2406_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	008	0	1	04	01	H2406_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				356.00	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	25						25			25			25		25
H2406	009	0	1	04	01	H2406_009_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	009	0	1	04	01	H2406_009_0	4			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																														
H2406	009	0	1	04	01	H2406_009_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H2406	009	0	1	04	01	H2406_009_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				98.00	38																				38																	38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	009	0	1	04	01	H2406_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	010	0	1	04	01	H2406_010_0	9			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	010	0	1	04	01	H2406_010_0	9			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	010	0	1	04	01	H2406_010_0	9			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	010	0	1	04	01	H2406_010_0	9			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				93.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	010	0	1	04	01	H2406_010_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H2406	011	0	1	04	01	H2406_011_0	9			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	011	0	1	04	01	H2406_011_0	9			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	011	0	1	04	01	H2406_011_0	9			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	011	0	1	04	01	H2406_011_0	9			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	011	0	1	04	01	H2406_011_0	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	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	25						25			25			25		25
H2406	013	0	1	04	01	H2406_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	013	0	1	04	01	H2406_013_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	013	0	1	04	01	H2406_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2406	013	0	1	04	01	H2406_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	013	0	1	04	01	H2406_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				356.00	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	25						25			25			25		25
H2406	015	0	1	04	01	H2406_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	015	0	1	04	01	H2406_015_0	4			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																														
H2406	015	0	1	04	01	H2406_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H2406	015	0	1	04	01	H2406_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				87.00	34																				34																	34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	015	0	1	04	01	H2406_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				393.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	016	0	1	04	01	H2406_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	016	0	1	04	01	H2406_016_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	016	0	1	04	01	H2406_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	016	0	1	04	01	H2406_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				96.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	016	0	1	04	01	H2406_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	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	25						25			25			25		25
H2406	017	0	1	04	01	H2406_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	017	0	1	04	01	H2406_017_0	4			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																														
H2406	017	0	1	04	01	H2406_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	017	0	1	04	01	H2406_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	017	0	1	04	01	H2406_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				369.00	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	25						25			25			25		25
H2406	018	0	1	04	01	H2406_018_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	018	0	1	04	01	H2406_018_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	018	0	1	04	01	H2406_018_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	018	0	1	04	01	H2406_018_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				93.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	018	0	1	04	01	H2406_018_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H2406	019	0	1	04	01	H2406_019_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	019	0	1	04	01	H2406_019_0	4			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																														
H2406	019	0	1	04	01	H2406_019_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H2406	019	0	1	04	01	H2406_019_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				91.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	019	0	1	04	01	H2406_019_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				366.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	034	0	1	04	01	H2406_034_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	034	0	1	04	01	H2406_034_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	034	0	1	04	01	H2406_034_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	034	0	1	04	01	H2406_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	034	0	1	04	01	H2406_034_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				403.00	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	25						25			25			25		25
H2406	035	0	1	04	01	H2406_035_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	035	0	1	04	01	H2406_035_0	5			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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	035	0	1	04	01	H2406_035_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2406	035	0	1	04	01	H2406_035_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	035	0	1	04	01	H2406_035_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				405.00	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	25						25			25			25		25
H2406	036	0	1	04	01	H2406_036_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	036	0	1	04	01	H2406_036_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	036	0	1	04	01	H2406_036_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H2406	036	0	1	04	01	H2406_036_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	036	0	1	04	01	H2406_036_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	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	25						25			25			25		25
H2406	037	0	1	04	01	H2406_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	037	0	1	04	01	H2406_037_0	4			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																														
H2406	037	0	1	04	01	H2406_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H2406	037	0	1	04	01	H2406_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				82.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	037	0	1	04	01	H2406_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				385.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	038	0	1	04	01	H2406_038_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	038	0	1	04	01	H2406_038_0	4			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																														
H2406	038	0	1	04	01	H2406_038_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H2406	038	0	1	04	01	H2406_038_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				78.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	038	0	1	04	01	H2406_038_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				391.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	039	0	1	04	01	H2406_039_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	039	0	1	04	01	H2406_039_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	039	0	1	04	01	H2406_039_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	039	0	1	04	01	H2406_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	039	0	1	04	01	H2406_039_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H2406	040	0	1	04	01	H2406_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	040	0	1	04	01	H2406_040_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	040	0	1	04	01	H2406_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				54.00	22		22																										22						22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	22		22						22			22	22		22
H2406	040	0	1	04	01	H2406_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				100.00	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	25						25			25			25		25
H2406	040	0	1	04	01	H2406_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				413.00	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	25						25			25			25		25
H2406	042	0	1	04	01	H2406_042_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	042	0	1	04	01	H2406_042_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	042	0	1	04	01	H2406_042_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	042	0	1	04	01	H2406_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	042	0	1	04	01	H2406_042_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				384.00	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	25						25			25			25		25
H2406	043	0	1	04	01	H2406_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																														
H2406	043	0	1	04	01	H2406_043_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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	043	0	1	04	01	H2406_043_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2406	043	0	1	04	01	H2406_043_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	043	0	1	04	01	H2406_043_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
H2406	044	0	1	04	01	H2406_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	044	0	1	04	01	H2406_044_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	044	0	1	04	01	H2406_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	044	0	1	04	01	H2406_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	044	0	1	04	01	H2406_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H2406	046	0	1	04	01	H2406_046_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	046	0	1	04	01	H2406_046_0	4			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																														
H2406	046	0	1	04	01	H2406_046_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				40.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H2406	046	0	1	04	01	H2406_046_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	046	0	1	04	01	H2406_046_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				354.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	047	0	1	04	01	H2406_047_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	047	0	1	04	01	H2406_047_0	4			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																														
H2406	047	0	1	04	01	H2406_047_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2406	047	0	1	04	01	H2406_047_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				70.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	047	0	1	04	01	H2406_047_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				401.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	048	0	1	04	01	H2406_048_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	048	0	1	04	01	H2406_048_0	4			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																														
H2406	048	0	1	04	01	H2406_048_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				40.00	17		17																				17															17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	17		17						17				17		17
H2406	048	0	1	04	01	H2406_048_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				91.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	048	0	1	04	01	H2406_048_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				400.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	050	0	1	04	01	H2406_050_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2406	050	0	1	04	01	H2406_050_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	050	0	1	04	01	H2406_050_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H2406	050	0	1	04	01	H2406_050_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				52.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	050	0	1	04	01	H2406_050_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				391.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	052	0	1	04	01	H2406_052_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2406	052	0	1	04	01	H2406_052_0	4		N	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																														
H2406	052	0	1	04	01	H2406_052_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H2406	052	0	1	04	01	H2406_052_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				53.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	052	0	1	04	01	H2406_052_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	053	0	1	04	01	H2406_053_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2406	053	0	1	04	01	H2406_053_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	053	0	1	04	01	H2406_053_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2406	053	0	1	04	01	H2406_053_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	053	0	1	04	01	H2406_053_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				400.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	054	0	1	04	01	H2406_054_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	054	0	1	04	01	H2406_054_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	054	0	1	04	01	H2406_054_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	054	0	1	04	01	H2406_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	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	25						25			25			25		25
H2406	054	0	1	04	01	H2406_054_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H2406	055	0	1	04	01	H2406_055_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	055	0	1	04	01	H2406_055_0	5			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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	055	0	1	04	01	H2406_055_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	055	0	1	04	01	H2406_055_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	055	0	1	04	01	H2406_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	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	25						25			25			25		25
H2406	056	0	1	04	01	H2406_056_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	056	0	1	04	01	H2406_056_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	056	0	1	04	01	H2406_056_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	056	0	1	04	01	H2406_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	056	0	1	04	01	H2406_056_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
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						0.39	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	058	0	1	04	01	H2406_058_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	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	25						25			25			25		25
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				339.00	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	25						25			25			25		25
H2406	059	0	1	04	01	H2406_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	059	0	1	04	01	H2406_059_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	059	0	1	04	01	H2406_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	059	0	1	04	01	H2406_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				96.00	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	25						25			25			25		25
H2406	059	0	1	04	01	H2406_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H2406	062	0	1	04	01	H2406_062_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	062	0	1	04	01	H2406_062_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	062	0	1	04	01	H2406_062_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	062	0	1	04	01	H2406_062_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	062	0	1	04	01	H2406_062_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				365.00	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	25						25			25			25		25
H2406	063	0	1	04	01	H2406_063_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	063	0	1	04	01	H2406_063_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	063	0	1	04	01	H2406_063_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	063	0	1	04	01	H2406_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	063	0	1	04	01	H2406_063_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	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	25						25			25			25		25
H2406	065	0	1	04	01	H2406_065_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	065	0	1	04	01	H2406_065_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	065	0	1	04	01	H2406_065_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	065	0	1	04	01	H2406_065_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H2406	066	0	1	04	01	H2406_066_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	066	0	1	04	01	H2406_066_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	066	0	1	04	01	H2406_066_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	066	0	1	04	01	H2406_066_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	066	0	1	04	01	H2406_066_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H2406	067	0	1	04	01	H2406_067_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	067	0	1	04	01	H2406_067_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	067	0	1	04	01	H2406_067_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	067	0	1	04	01	H2406_067_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	067	0	1	04	01	H2406_067_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				356.00	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	25						25			25			25		25
H2406	068	0	1	04	01	H2406_068_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	068	0	1	04	01	H2406_068_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	068	0	1	04	01	H2406_068_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	068	0	1	04	01	H2406_068_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	068	0	1	04	01	H2406_068_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				399.00	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	25						25			25			25		25
H2406	069	0	1	04	01	H2406_069_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	069	0	1	04	01	H2406_069_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	069	0	1	04	01	H2406_069_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	069	0	1	04	01	H2406_069_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	069	0	1	04	01	H2406_069_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
H2406	070	0	1	04	01	H2406_070_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	070	0	1	04	01	H2406_070_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	070	0	1	04	01	H2406_070_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	070	0	1	04	01	H2406_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	070	0	1	04	01	H2406_070_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H2406	071	0	1	04	01	H2406_071_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	071	0	1	04	01	H2406_071_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	071	0	1	04	01	H2406_071_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	071	0	1	04	01	H2406_071_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	071	0	1	04	01	H2406_071_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				458.00	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	25						25			25			25		25
H2406	072	0	1	04	01	H2406_072_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	072	0	1	04	01	H2406_072_0	4			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																														
H2406	072	0	1	04	01	H2406_072_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H2406	072	0	1	04	01	H2406_072_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				71.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	072	0	1	04	01	H2406_072_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				386.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	075	0	1	04	01	H2406_075_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	075	0	1	04	01	H2406_075_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	075	0	1	04	01	H2406_075_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	075	0	1	04	01	H2406_075_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	075	0	1	04	01	H2406_075_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	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	25						25			25			25		25
H2406	076	0	1	04	01	H2406_076_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	076	0	1	04	01	H2406_076_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	076	0	1	04	01	H2406_076_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	076	0	1	04	01	H2406_076_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	076	0	1	04	01	H2406_076_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				335.00	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	25						25			25			25		25
H2406	078	0	1	04	01	H2406_078_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	078	0	1	04	01	H2406_078_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	078	0	1	04	01	H2406_078_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	078	0	1	04	01	H2406_078_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	078	0	1	04	01	H2406_078_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H2406	082	0	1	04	01	H2406_082_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	082	0	1	04	01	H2406_082_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	082	0	1	04	01	H2406_082_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	082	0	1	04	01	H2406_082_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	082	0	1	04	01	H2406_082_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	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	25						25			25			25		25
H2406	087	0	1	04	01	H2406_087_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	087	0	1	04	01	H2406_087_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	087	0	1	04	01	H2406_087_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	087	0	1	04	01	H2406_087_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	087	0	1	04	01	H2406_087_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H2406	088	0	1	04	01	H2406_088_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	088	0	1	04	01	H2406_088_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	088	0	1	04	01	H2406_088_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	088	0	1	04	01	H2406_088_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	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	25						25			25			25		25
H2406	088	0	1	04	01	H2406_088_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				352.00	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	25						25			25			25		25
H2406	089	0	1	04	01	H2406_089_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	089	0	1	04	01	H2406_089_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	2.00		6.00																											6.00						0.00				2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	089	0	1	04	01	H2406_089_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				49.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H2406	089	0	1	04	01	H2406_089_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	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	25						25			25			25		25
H2406	089	0	1	04	01	H2406_089_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H2406	090	0	1	04	01	H2406_090_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	090	0	1	04	01	H2406_090_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	090	0	1	04	01	H2406_090_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2406	090	0	1	04	01	H2406_090_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	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	25						25			25			25		25
H2406	090	0	1	04	01	H2406_090_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H2406	091	0	1	04	01	H2406_091_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	091	0	1	04	01	H2406_091_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	091	0	1	04	01	H2406_091_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2406	091	0	1	04	01	H2406_091_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	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	25						25			25			25		25
H2406	091	0	1	04	01	H2406_091_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				361.00	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	25						25			25			25		25
H2406	093	0	1	04	01	H2406_093_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	093	0	1	04	01	H2406_093_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	093	0	1	04	01	H2406_093_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H2406	093	0	1	04	01	H2406_093_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	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	25						25			25			25		25
H2406	093	0	1	04	01	H2406_093_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H2406	096	0	1	04	01	H2406_096_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	096	0	1	04	01	H2406_096_0	4			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																														
H2406	096	0	1	04	01	H2406_096_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				41.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H2406	096	0	1	04	01	H2406_096_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				90.00	36																				36																	36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	096	0	1	04	01	H2406_096_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	097	0	1	04	01	H2406_097_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	097	0	1	04	01	H2406_097_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	097	0	1	04	01	H2406_097_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				49.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2406	097	0	1	04	01	H2406_097_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	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	25						25			25			25		25
H2406	097	0	1	04	01	H2406_097_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	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	25						25			25			25		25
H2406	098	0	1	04	01	H2406_098_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	098	0	1	04	01	H2406_098_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	098	0	1	04	01	H2406_098_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	098	0	1	04	01	H2406_098_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	098	0	1	04	01	H2406_098_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H2406	099	0	1	04	01	H2406_099_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2406	099	0	1	04	01	H2406_099_0	4		N	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																														
H2406	099	0	1	04	01	H2406_099_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H2406	099	0	1	04	01	H2406_099_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				59.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	099	0	1	04	01	H2406_099_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				419.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	100	0	1	04	01	H2406_100_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	100	0	1	04	01	H2406_100_0	4			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																														
H2406	100	0	1	04	01	H2406_100_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				42.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H2406	100	0	1	04	01	H2406_100_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				78.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	100	0	1	04	01	H2406_100_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	101	0	1	04	01	H2406_101_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	101	0	1	04	01	H2406_101_0	5			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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	101	0	1	04	01	H2406_101_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	101	0	1	04	01	H2406_101_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	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	25						25			25			25		25
H2406	101	0	1	04	01	H2406_101_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				362.00	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	25						25			25			25		25
H2406	104	0	1	04	01	H2406_104_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	104	0	1	04	01	H2406_104_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	104	0	1	04	01	H2406_104_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	104	0	1	04	01	H2406_104_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	104	0	1	04	01	H2406_104_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H2406	110	0	1	04	01	H2406_110_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	110	0	1	04	01	H2406_110_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	110	0	1	04	01	H2406_110_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2406	110	0	1	04	01	H2406_110_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				99.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	110	0	1	04	01	H2406_110_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H2406	112	0	1	04	01	H2406_112_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	112	0	1	04	01	H2406_112_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	112	0	1	04	01	H2406_112_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	112	0	1	04	01	H2406_112_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	112	0	1	04	01	H2406_112_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H2406	113	0	1	04	01	H2406_113_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	113	0	1	04	01	H2406_113_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	113	0	1	04	01	H2406_113_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	113	0	1	04	01	H2406_113_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	113	0	1	04	01	H2406_113_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				340.00	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	25						25			25			25		25
H2406	115	0	1	04	01	H2406_115_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	115	0	1	04	01	H2406_115_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	115	0	1	04	01	H2406_115_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2406	115	0	1	04	01	H2406_115_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	115	0	1	04	01	H2406_115_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	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	25						25			25			25		25
H2406	119	0	1	04	01	H2406_119_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	119	0	1	04	01	H2406_119_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	119	0	1	04	01	H2406_119_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2406	119	0	1	04	01	H2406_119_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	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	25						25			25			25		25
H2406	119	0	1	04	01	H2406_119_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H2406	121	0	1	04	01	H2406_121_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	121	0	1	04	01	H2406_121_0	4			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																														
H2406	121	0	1	04	01	H2406_121_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H2406	121	0	1	04	01	H2406_121_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				64.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	121	0	1	04	01	H2406_121_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				385.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2406	125	0	1	04	01	H2406_125_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	125	0	1	04	01	H2406_125_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	125	0	1	04	01	H2406_125_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	125	0	1	04	01	H2406_125_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	125	0	1	04	01	H2406_125_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				326.00	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	25						25			25			25		25
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		0.27						0.26	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2406	129	0	1	04	01	H2406_129_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				44.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				289.00	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	25						25			25			25		25
H2406	135	0	1	04	01	H2406_135_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	135	0	1	04	01	H2406_135_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2406	135	0	1	04	01	H2406_135_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2406	135	0	1	04	01	H2406_135_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2406	135	0	1	04	01	H2406_135_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H2441	001	0	1	04	01	H2441_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	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	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				78.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2441	001	0	1	04	01	H2441_001_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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2441	001	0	1	04	01	H2441_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2441	001	0	1	04	01	H2441_001_0	6		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																														
H2445	001	0	1	02	01	H2445_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2445	001	0	1	02	01	H2445_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2445	001	0	1	02	01	H2445_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H2445	001	0	1	02	01	H2445_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	001	0	1	02	01	H2445_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				335.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	002	0	1	02	01	H2445_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2445	002	0	1	02	01	H2445_002_0	4		N	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																														
H2445	002	0	1	02	01	H2445_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2445	002	0	1	02	01	H2445_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	002	0	1	02	01	H2445_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				366.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	003	0	1	02	01	H2445_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2445	003	0	1	02	01	H2445_003_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2445	003	0	1	02	01	H2445_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H2445	003	0	1	02	01	H2445_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	003	0	1	02	01	H2445_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				366.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	004	0	1	02	01	H2445_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2445	004	0	1	02	01	H2445_004_0	4		N	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																														
H2445	004	0	1	02	01	H2445_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H2445	004	0	1	02	01	H2445_004_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2445	004	0	1	02	01	H2445_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	005	0	1	02	01	H2445_005_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2445	005	0	1	02	01	H2445_005_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2445	005	0	1	02	01	H2445_005_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H2445	005	0	1	02	01	H2445_005_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2445	005	0	1	02	01	H2445_005_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	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	9.00	18.00	27.00																									19.00	38.00	57.00				9.00	18.00	27.00				9.00				9.00		0.30				0.63	0.30	0.29	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				43.29	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	20	20	20				20	20	20	20	20	20	20		20
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				61.78	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2450	007	0	1	18	06	H2450_007_0	4			Preferred Generic	3	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																									17.00	34.00	51.00				7.00	14.00	21.00				7.00				7.00		0.23				0.57	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2450	007	0	1	18	06	H2450_007_0	4			Generic	3	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																									20.00	40.00	60.00				14.00	28.00	42.00				14.00				14.00		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	4			Preferred Brand	3	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				44.76	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		35.00	17	17	17				17	17	17	17	17	17	17		17
H2450	007	0	1	18	06	H2450_007_0	4			Non-Preferred Drug	3	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				72.79	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		35.00	25	25	25				25	25	25	25	25	25	25		25
H2450	007	0	1	18	06	H2450_007_0	4			Specialty Tier	3	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2450	016	0	1	18	06	H2450_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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	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																									18.00	36.00	54.00				8.00	16.00	24.00				8.00				8.00		0.27				0.60	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2450	016	0	1	18	06	H2450_016_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				36.55	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		35.00	16	16	16				16	16	16	16	16	16	16		16
H2450	016	0	1	18	06	H2450_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				64.86	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		35.00	25	25	25				25	25	25	25	25	25	25		25
H2450	016	0	1	18	06	H2450_016_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																														
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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	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	9.00	18.00	27.00																									19.00	38.00	57.00				9.00	18.00	27.00				9.00				9.00		0.30				0.63	0.30	0.29	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				38.14	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		35.00	16	16	16				16	16	16	16	16	16	16		16
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				72.66	50	50	50																								50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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			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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	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	7.00	14.00	21.00																									17.00	34.00	51.00				7.00	14.00	21.00				7.00				7.00		0.23				0.57	0.23	0.23	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				33.53	16	16	16																								16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	16	16	16				16	16	16	16	16	16	16		16
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				63.39	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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			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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	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	10.00	20.00	30.00																									20.00	40.00	60.00				10.00	20.00	30.00				10.00				10.00		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				36.94	16	16	16																								16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	16	16	16				16	16	16	16	16	16	16		16
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				61.93	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		35.00	25	25	25				25	25	25	25	25	25	25		25
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								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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	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	16.00	32.00	48.00																									20.00	40.00	60.00				16.00	32.00	48.00				16.00				16.00		0.53				0.67	0.53	0.52	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				43.04	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		35.00	18	18	18				18	18	18	18	18	18	18		18
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				80.75	50	50	50																								50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2458	002	0	1	01	01	H2458_002_0	8		N	Preferred Generic	4	01	1	1	1	1	110		01		110	1	30		90				2	2				30		90	30		31				1.90	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2458	002	0	1	01	01	H2458_002_0	8		N	Generic	4	01	1	1	2	1	110		01		110	1	30		90				2	2				30		90	30		31				5.76	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2458	002	0	1	01	01	H2458_002_0	8		N	Preferred Brand	4	10	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				48.87	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	25		25				25		25	25		25	25		25
H2458	002	0	1	01	01	H2458_002_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				2	2				30		90	30		31				53.09	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	25		25				25		25	25		25	25		25
H2458	002	0	1	01	01	H2458_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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2458	002	0	1	01	01	H2458_002_0	8		N	Select Care Drugs	4	01	1	2	6	1	110		01		110	1	30		90				2	2				30		90	30		31	0.00		0.00																									1.00		1.00				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																														
H2461	008	0	1	18	06	H2461_008_0	2			Preferred Generic	2	11	1	2	1	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	25	25	22				25	25	25	25	25	25	25		25
H2461	008	0	1	18	06	H2461_008_0	2			Generic	2	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	15.00	30.00	30.00																									20.00	40.00	40.00				15.00	30.00	30.00				15.00				15.00		0.48				0.65	0.48	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	30.00				20.00	40.00	40.00	15.00	30.00	30.00	15.00		15.00	25	25	25				25	25	25	25	25	25	25		25
H2461	008	0	1	18	06	H2461_008_0	2			Preferred Brand	2	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				44.10	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H2461	008	0	1	18	06	H2461_008_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				66.53	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	25	25	25				25	25	25	25	25	25	25		25
H2461	008	0	1	18	06	H2461_008_0	2			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	2			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									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	25	25	25				25	25	25	25	25	25	25		25
H2461	009	0	1	18	06	H2461_009_0	2			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									15.00	30.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.48	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				15.00	30.00	30.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H2461	009	0	1	18	06	H2461_009_0	2			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				46.87	23	23	23																								24	24	24				23	23	23			23			23								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	23	23	23				23	23	23	23	23	23	23		23
H2461	009	0	1	18	06	H2461_009_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				98.89	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	25	25	25				25	25	25	25	25	25	25		25
H2461	009	0	1	18	06	H2461_009_0	2			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	3			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	25	25	25				25	25	25	25	25	25	25		25
H2461	010	0	1	18	06	H2461_010_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	25	25	25				25	25	25	25	25	25	25		25
H2461	010	0	1	18	06	H2461_010_0	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				42.97	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22				22	22	22	22	22	22	22		22
H2461	010	0	1	18	06	H2461_010_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				88.53	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	25	25	25				25	25	25	25	25	25	25		25
H2461	010	0	1	18	06	H2461_010_0	3			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	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	0		0				25		25	0		0	0		0
H2463	001	0	1	01	01	H2463_001_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	0		0				25		25	0		0	0		0
H2463	001	0	1	01	01	H2463_001_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	25		25				25		25	25		25	25		25
H2463	001	0	1	01	01	H2463_001_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H2463	001	0	1	01	01	H2463_001_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	25						25			25			25		25
H2478	001	0	1	01	01	H2478_001_0	9		N	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																														
H2478	001	0	1	01	01	H2478_001_0	9		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2478	001	0	1	01	01	H2478_001_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				35.65	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		35.00	20	20	20				20	20	20				20		20
H2478	001	0	1	01	01	H2478_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				72.34	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		35.00	25	25	25				25	25	25				25		25
H2478	001	0	1	01	01	H2478_001_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				684.54	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	25						25						25		25
H2478	001	0	1	01	01	H2478_001_0	9		N	Select Care Drugs	4	01	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																														
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	0		0				25		25	0		0	0		0
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	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				83.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H2486	007	0	1	01	01	H2486_007_0	2			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	0		0				25		25	0		0	0		0
H2486	007	0	1	01	01	H2486_007_0	2			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	25		25				25		25	25		0	25		25
H2486	007	0	1	01	01	H2486_007_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H2486	007	0	1	01	01	H2486_007_0	2			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	25		25				25		25	25		25	25		25
H2486	007	0	1	01	01	H2486_007_0	2			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	25						25			25			25		25
H2491	010	0	1	02	01	H2491_010_0	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	010	0	1	02	01	H2491_010_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.00	25	25	25				104.00	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	010	0	1	02	01	H2491_010_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	010	0	1	02	01	H2491_010_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2491	017	0	1	02	01	H2491_017_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2491	017	0	1	02	01	H2491_017_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.95	25	25	25				129.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	017	0	1	02	01	H2491_017_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											60.21	40	40	40				58.71	39	39	39											40	40					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	017	0	1	02	01	H2491_017_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	017	0	1	02	01	H2491_017_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	025	0	1	02	01	H2491_025_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	025	0	1	02	01	H2491_025_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	025	0	1	02	01	H2491_025_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											103.82	25	25	25				103.82	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	025	0	1	02	01	H2491_025_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	025	0	1	02	01	H2491_025_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	025	0	1	02	01	H2491_025_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2491	028	0	1	02	01	H2491_028_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2491	028	0	1	02	01	H2491_028_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.38	25	25	25				129.38	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	028	0	1	02	01	H2491_028_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.02	36	36	36				69.02	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	028	0	1	02	01	H2491_028_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	028	0	1	02	01	H2491_028_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2491	029	0	1	02	01	H2491_029_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2491	029	0	1	02	01	H2491_029_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.46	25	25	25				122.46	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	029	0	1	02	01	H2491_029_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											58.10	35	35	35				58.10	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	029	0	1	02	01	H2491_029_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	029	0	1	02	01	H2491_029_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	031	0	1	02	01	H2491_031_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2491	031	0	1	02	01	H2491_031_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2491	031	0	1	02	01	H2491_031_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											117.52	25	25	25				117.52	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	031	0	1	02	01	H2491_031_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.02	50	50	50				72.54	49	49	49											50	50					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	031	0	1	02	01	H2491_031_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	031	0	1	02	01	H2491_031_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	1	1	02	01	H2491_032_1	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	1	1	02	01	H2491_032_1	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	1	1	02	01	H2491_032_1	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.94	20	20	20				86.94	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H2491	032	1	1	02	01	H2491_032_1	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											37.12	32	32	32				37.12	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	032	1	1	02	01	H2491_032_1	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	1	1	02	01	H2491_032_1	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	2	1	02	01	H2491_032_2	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	2	1	02	01	H2491_032_2	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	2	1	02	01	H2491_032_2	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.94	20	20	20				86.94	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H2491	032	2	1	02	01	H2491_032_2	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											37.12	32	32	32				37.12	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	032	2	1	02	01	H2491_032_2	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	032	2	1	02	01	H2491_032_2	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	1	1	02	01	H2491_033_1	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	1	1	02	01	H2491_033_1	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	1	1	02	01	H2491_033_1	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											106.19	25	25	25				106.19	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	033	1	1	02	01	H2491_033_1	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	033	1	1	02	01	H2491_033_1	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	1	1	02	01	H2491_033_1	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	2	1	02	01	H2491_033_2	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	2	1	02	01	H2491_033_2	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	2	1	02	01	H2491_033_2	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											106.19	25	25	25				106.19	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	033	2	1	02	01	H2491_033_2	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2491	033	2	1	02	01	H2491_033_2	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2491	033	2	1	02	01	H2491_033_2	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2509	001	0	1	02	01	H2509_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2509	001	0	1	02	01	H2509_001_0	4		N	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																														
H2509	001	0	1	02	01	H2509_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	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	25		25						25				25		25
H2509	001	0	1	02	01	H2509_001_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2509	001	0	1	02	01	H2509_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				369.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2509	002	0	1	02	01	H2509_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2509	002	0	1	02	01	H2509_002_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2509	002	0	1	02	01	H2509_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H2509	002	0	1	02	01	H2509_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2509	002	0	1	02	01	H2509_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				385.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2509	003	0	1	02	01	H2509_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2509	003	0	1	02	01	H2509_003_0	4		N	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																														
H2509	003	0	1	02	01	H2509_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H2509	003	0	1	02	01	H2509_003_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2509	003	0	1	02	01	H2509_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				405.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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				32.00	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	19	19	19				19	19	19				19		19
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2564	001	0	1	01	01	H2564_001_0	10		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				5.00	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2564	001	0	1	01	01	H2564_001_0	10		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				14.27	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H2564	001	0	1	01	01	H2564_001_0	10		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				109.06	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H2564	001	0	1	01	01	H2564_001_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				23.91	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H2564	001	0	1	01	01	H2564_001_0	10		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				587.76	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2564	001	0	1	01	01	H2564_001_0	10		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	001	0	1	02	01	H2593_001_0	4			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	001	0	1	02	01	H2593_001_0	4			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					0.00	0.00	0.00					0.00	0.00	0.00																2.00				2.00			0.07	0.00	0.00			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	001	0	1	02	01	H2593_001_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											35.00	15	15	15				59.00	15	15	15				15	15	15															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	70.00				35.00		35.00	15	15	15	15	15	15	15	15	15				15		15
H2593	001	0	1	02	01	H2593_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		34											56.00	30	30	30				35.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H2593	001	0	1	02	01	H2593_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	001	0	1	02	01	H2593_001_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H2593	003	0	1	01	01	H2593_003_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	003	0	1	01	01	H2593_003_0	7			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																														
H2593	003	0	1	01	01	H2593_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				83.00	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H2593	003	0	1	01	01	H2593_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				54.00	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		35.00	25	25	25				25	25	25				25		25
H2593	003	0	1	01	01	H2593_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	003	0	1	01	01	H2593_003_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2593	005	0	1	02	01	H2593_005_0	4			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	005	0	1	02	01	H2593_005_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	005	0	1	02	01	H2593_005_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.00	20	20	20				62.00	15	15	15				15	15	15															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	20	20	20	15	15	15	15	15	15				20		20
H2593	005	0	1	02	01	H2593_005_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.00	30	30	30				31.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H2593	005	0	1	02	01	H2593_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	005	0	1	02	01	H2593_005_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H2593	006	0	1	02	01	H2593_006_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	006	0	1	02	01	H2593_006_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.00	20	20	20				58.00	15	15	15				15	15	15															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	20	20	20	15	15	15	15	15	15				20		20
H2593	006	0	1	02	01	H2593_006_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											70.00	30	30	30				40.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H2593	006	0	1	02	01	H2593_006_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	006	0	1	02	01	H2593_006_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H2593	029	0	1	02	01	H2593_029_0	5			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																														
H2593	029	0	1	02	01	H2593_029_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	25	25	25				84.00	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	25	25	25	20	20	20	20	20	20				25		25
H2593	029	0	1	02	01	H2593_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											33.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H2593	029	0	1	02	01	H2593_029_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	029	0	1	02	01	H2593_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																														
H2593	031	0	1	02	01	H2593_031_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	031	0	1	02	01	H2593_031_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	031	0	1	02	01	H2593_031_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											33.00	15	15	15				36.00	10	10	10				10	10	10															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00	15	15	15	10	10	10	10	10	10				15		15
H2593	031	0	1	02	01	H2593_031_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											40.00	30	30	30				26.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H2593	031	0	1	02	01	H2593_031_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	031	0	1	02	01	H2593_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5		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																														
H2593	032	0	1	01	01	H2593_032_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	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	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				84.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	032	0	1	01	01	H2593_032_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		34				29.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	032	0	1	01	01	H2593_032_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	032	0	1	01	01	H2593_032_0	5		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																														
H2593	040	0	1	02	01	H2593_040_0	4			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	040	0	1	02	01	H2593_040_0	4			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	040	0	1	02	01	H2593_040_0	4			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	25.00	50.00	75.00	25.00	50.00	75.00	25.00	50.00	50.00				25.00		25.00	25	25	25	25	25	25	25	25	25				25		25
H2593	040	0	1	02	01	H2593_040_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.00	25	25	25				51.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H2593	040	0	1	02	01	H2593_040_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	040	0	1	02	01	H2593_040_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H2593	043	0	1	02	01	H2593_043_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	043	0	1	02	01	H2593_043_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											49.00	25	25	25				62.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H2593	043	0	1	02	01	H2593_043_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											34.00	25	25	25				17.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H2593	043	0	1	02	01	H2593_043_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	043	0	1	02	01	H2593_043_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																														
H2593	044	0	1	01	01	H2593_044_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	044	0	1	01	01	H2593_044_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, Select Care Drugs																														
H2593	044	0	1	01	01	H2593_044_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				85.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	044	0	1	01	01	H2593_044_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				29.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	044	0	1	01	01	H2593_044_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	044	0	1	01	01	H2593_044_0	6		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																														
H2593	045	0	1	01	01	H2593_045_0	5		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																														
H2593	045	0	1	01	01	H2593_045_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				2.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	045	0	1	01	01	H2593_045_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				85.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	045	0	1	01	01	H2593_045_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	045	0	1	01	01	H2593_045_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	045	0	1	01	01	H2593_045_0	5		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																														
H2593	046	0	1	01	01	H2593_046_0	5		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																														
H2593	046	0	1	01	01	H2593_046_0	5		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, Select Care Drugs																														
H2593	046	0	1	01	01	H2593_046_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				76.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	046	0	1	01	01	H2593_046_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		34				26.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	046	0	1	01	01	H2593_046_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	046	0	1	01	01	H2593_046_0	5		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																														
H2593	047	0	1	01	01	H2593_047_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	047	0	1	01	01	H2593_047_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, Select Care Drugs																														
H2593	047	0	1	01	01	H2593_047_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				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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	047	0	1	01	01	H2593_047_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				27.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	047	0	1	01	01	H2593_047_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	047	0	1	01	01	H2593_047_0	6		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																														
H2593	048	0	1	01	01	H2593_048_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	048	0	1	01	01	H2593_048_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	048	0	1	01	01	H2593_048_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				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	048	0	1	01	01	H2593_048_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				33.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	048	0	1	01	01	H2593_048_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	048	0	1	01	01	H2593_048_0	6		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																														
H2593	051	0	1	01	01	H2593_051_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	051	0	1	01	01	H2593_051_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, Select Care Drugs																														
H2593	051	0	1	01	01	H2593_051_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				86.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	051	0	1	01	01	H2593_051_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				27.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	051	0	1	01	01	H2593_051_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	051	0	1	01	01	H2593_051_0	6		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																														
H2593	053	0	1	01	01	H2593_053_0	5		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																														
H2593	053	0	1	01	01	H2593_053_0	5		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, Select Care Drugs																														
H2593	053	0	1	01	01	H2593_053_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	053	0	1	01	01	H2593_053_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		34				24.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2593	053	0	1	01	01	H2593_053_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2593	053	0	1	01	01	H2593_053_0	5		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																														
H2610	005	0	1	01	01	H2610_005_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H2610	005	0	1	01	01	H2610_005_0	9			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H2610	005	0	1	01	01	H2610_005_0	9			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					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	005	0	1	01	01	H2610_005_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					75.00	150.00	225.00					75.00	150.00	150.00																100.00				100.00			3.33	2.50	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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	005	0	1	01	01	H2610_005_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											746.46	33						746.46	33						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	25			25			25						25		25
H2610	005	0	1	01	01	H2610_005_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	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2610	006	0	1	01	01	H2610_006_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H2610	006	0	1	01	01	H2610_006_0	9			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H2610	006	0	1	01	01	H2610_006_0	9			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					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	006	0	1	01	01	H2610_006_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					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, 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	25	25	25	25	25	25	25	25	25				25		25
H2610	006	0	1	01	01	H2610_006_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											824.09	33						824.09	33						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	25			25			25						25		25
H2610	006	0	1	01	01	H2610_006_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	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2610	015	0	1	01	01	H2610_015_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					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	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00	25	25	25	0	0	0	0	0	0				25		25
H2610	015	0	1	01	01	H2610_015_0	8			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					3.00	6.00	9.00					3.00	6.00	6.00																10.00				10.00			0.33	0.10	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	3.00	6.00	6.00				10.00		10.00	25	25	25	25	25	25	25	25	25				25		25
H2610	015	0	1	01	01	H2610_015_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	015	0	1	01	01	H2610_015_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, 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	25	25	25	25	25	25	25	25	25				25		25
H2610	015	0	1	01	01	H2610_015_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											724.33	29						724.33	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	25			25			25						25		25
H2610	015	0	1	01	01	H2610_015_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2610	016	0	1	01	01	H2610_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								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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H2610	016	0	1	01	01	H2610_016_0	7			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H2610	016	0	1	01	01	H2610_016_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	016	0	1	01	01	H2610_016_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					75.00	150.00	225.00					75.00	150.00	150.00																100.00				100.00			3.33	2.50	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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	016	0	1	01	01	H2610_016_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											712.96	29						712.96	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	25			25			25						25		25
H2610	016	0	1	01	01	H2610_016_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2610	021	0	1	01	01	H2610_021_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					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	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		5.00	25	25	25	0	0	0	0	0	0				25		25
H2610	021	0	1	01	01	H2610_021_0	8			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					3.00	6.00	9.00					3.00	6.00	6.00																10.00				10.00			0.33	0.10	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	3.00	6.00	6.00				10.00		10.00	25	25	25	25	25	25	25	25	25				25		25
H2610	021	0	1	01	01	H2610_021_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	021	0	1	01	01	H2610_021_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					95.00	190.00	190.00																100.00				100.00			3.33	3.17	3.17			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, 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	25	25	25	25	25	25	25	25	25				25		25
H2610	021	0	1	01	01	H2610_021_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											830.39	29						830.39	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	25			25			25						25		25
H2610	021	0	1	01	01	H2610_021_0	8			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2610	027	0	1	01	01	H2610_027_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H2610	027	0	1	01	01	H2610_027_0	7			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H2610	027	0	1	01	01	H2610_027_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	90.00																47.00				47.00			1.57	1.50	1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H2610	027	0	1	01	01	H2610_027_0	7			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					95.00	190.00	285.00					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, 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	25	25	25	25	25	25	25	25	25				25		25
H2610	027	0	1	01	01	H2610_027_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											705.54	33						705.54	33						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	25			25			25						25		25
H2610	027	0	1	01	01	H2610_027_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H2624	001	0	1	01	01	H2624_001_0	6			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	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																														
H2624	001	0	1	01	01	H2624_001_0	6			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	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, Select Care Drugs																														
H2624	001	0	1	01	01	H2624_001_0	6			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											47.80	25	25	25				48.54	25	25	25				25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2624	001	0	1	01	01	H2624_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											69.20	50	50	50				56.45	40	40	40				40	40	40																50		50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H2624	001	0	1	01	01	H2624_001_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31											272.23	29						234.06	29						29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2624	001	0	1	01	01	H2624_001_0	6			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	0	0	0	0	0	0	0	0	0				0		0
H2628	001	0	1	01	01	H2628_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		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																														
H2628	001	0	1	01	01	H2628_001_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2628	001	0	1	01	01	H2628_001_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	001	0	1	01	01	H2628_001_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		34				29.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	001	0	1	01	01	H2628_001_0	5		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																														
H2628	001	0	1	01	01	H2628_001_0	5		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																														
H2628	003	0	1	01	01	H2628_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		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																														
H2628	003	0	1	01	01	H2628_003_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2628	003	0	1	01	01	H2628_003_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	003	0	1	01	01	H2628_003_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	003	0	1	01	01	H2628_003_0	5		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																														
H2628	003	0	1	01	01	H2628_003_0	5		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																														
H2628	004	0	1	01	01	H2628_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		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																														
H2628	004	0	1	01	01	H2628_004_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2628	004	0	1	01	01	H2628_004_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	004	0	1	01	01	H2628_004_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	004	0	1	01	01	H2628_004_0	5		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																														
H2628	004	0	1	01	01	H2628_004_0	5		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																														
H2628	005	0	1	01	01	H2628_005_0	5		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																														
H2628	005	0	1	01	01	H2628_005_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2628	005	0	1	01	01	H2628_005_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	005	0	1	01	01	H2628_005_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2628	005	0	1	01	01	H2628_005_0	5		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																														
H2628	005	0	1	01	01	H2628_005_0	5		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																														
H2630	001	0	1	01	01	H2630_001_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2630	001	0	1	01	01	H2630_001_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2630	001	0	1	01	01	H2630_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	40.00	80.00	120.00																					80.00																40.00				40.00		1.33						1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						80.00				35.00		35.00	25	25	25						25				25		25
H2630	001	0	1	01	01	H2630_001_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				40.32	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	25						25						25		25
H2630	001	0	1	01	01	H2630_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				268.34	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	25						25						25		25
H2630	001	0	1	01	01	H2630_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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2630	002	0	1	01	01	H2630_002_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2630	002	0	1	01	01	H2630_002_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2630	002	0	1	01	01	H2630_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	35.00	70.00	105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						70.00				35.00		35.00	25	25	25						25				25		25
H2630	002	0	1	01	01	H2630_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				33.31	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	25						25						25		25
H2630	002	0	1	01	01	H2630_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				192.67	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	25						25						25		25
H2630	002	0	1	01	01	H2630_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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H2663	005	0	1	02	01	H2663_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																														
H2663	005	0	1	02	01	H2663_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																														
H2663	005	0	1	02	01	H2663_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											69.32	24	24	24				97.25	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	005	0	1	02	01	H2663_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											37.76	25	25	25				45.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	005	0	1	02	01	H2663_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											493.41	25						617.37	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	25			25			25			25			25		25
H2663	006	0	1	02	01	H2663_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																														
H2663	006	0	1	02	01	H2663_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																														
H2663	006	0	1	02	01	H2663_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											64.34	24	24	24				87.01	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	006	0	1	02	01	H2663_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											42.01	25	25	25				43.31	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	006	0	1	02	01	H2663_006_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											503.65	25						572.55	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	25			25			25			25			25		25
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											67.41	24	24	24				93.11	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.03	25	25	25				44.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											536.92	25						633.04	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	25			25			25			25			25		25
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											60.52	24	24	24				85.26	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											35.38	25	25	25				46.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											474.34	25						642.24	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											60.64	24	24	24				92.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											32.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											517.63	25						703.84	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	25			25			25			25			25		25
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											65.93	24	24	24				93.49	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.64	25	25	25				42.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											524.18	25						603.51	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	25			25			25			25			25		25
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											62.40	24	24	24				85.37	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											32.20	25	25	25				39.10	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.90	25						692.23	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	25			25			25			25			25		25
H2663	029	0	1	02	01	H2663_029_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	029	0	1	02	01	H2663_029_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	029	0	1	02	01	H2663_029_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				86.77	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	029	0	1	02	01	H2663_029_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				41.44	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	029	0	1	02	01	H2663_029_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				504.42	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2663	034	0	1	01	01	H2663_034_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	034	0	1	01	01	H2663_034_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	034	0	1	01	01	H2663_034_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.50	24	24	24				92.64	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	034	0	1	01	01	H2663_034_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											39.20	25	25	25				45.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	034	0	1	01	01	H2663_034_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											555.16	25						635.10	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	25			25			25			25			25		25
H2663	038	0	1	02	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	02	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	02	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											66.03	24	24	24				90.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	038	0	1	02	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											35.86	25	25	25				42.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	038	0	1	02	01	H2663_038_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											489.68	25						592.10	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	25			25			25			25			25		25
H2663	039	0	1	01	01	H2663_039_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	039	0	1	01	01	H2663_039_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	039	0	1	01	01	H2663_039_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				84.57	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	039	0	1	01	01	H2663_039_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				41.81	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	039	0	1	01	01	H2663_039_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				533.14	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2663	040	0	1	02	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	02	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	02	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											68.61	24	24	24				91.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	040	0	1	02	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											40.90	25	25	25				46.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	040	0	1	02	01	H2663_040_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											523.90	25						659.92	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	25			25			25			25			25		25
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											70.81	24	24	24				93.23	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.82	25	25	25				44.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											524.01	25						664.46	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	25			25			25			25			25		25
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											70.39	24	24	24				93.57	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.13	25	25	25				45.09	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											584.34	25						656.53	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	25			25			25			25			25		25
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											67.85	24	24	24				94.65	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.15	25	25	25				45.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											505.87	25						685.12	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	25			25			25			25			25		25
H2663	052	0	1	01	01	H2663_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																														
H2663	052	0	1	01	01	H2663_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																														
H2663	052	0	1	01	01	H2663_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											68.43	22	22	22				84.80	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	052	0	1	01	01	H2663_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											38.39	25	25	25				45.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	052	0	1	01	01	H2663_052_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											531.39	25						586.29	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	25			25			25			25			25		25
H2663	053	0	1	01	01	H2663_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																														
H2663	053	0	1	01	01	H2663_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																														
H2663	053	0	1	01	01	H2663_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											62.65	22	22	22				82.72	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	053	0	1	01	01	H2663_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											38.78	25	25	25				47.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	053	0	1	01	01	H2663_053_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											551.97	25						534.42	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	25			25			25			25			25		25
H2663	056	0	1	01	01	H2663_056_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.68	22	22	22				90.49	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	056	0	1	01	01	H2663_056_0	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				52.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	056	0	1	01	01	H2663_056_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											565.89	25						598.46	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	25			25			25			25			25		25
H2663	057	0	1	02	01	H2663_057_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.18	22	22	22				85.97	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	057	0	1	02	01	H2663_057_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.40	25	25	25				52.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	057	0	1	02	01	H2663_057_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											531.64	25						570.82	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	25			25			25			25			25		25
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											62.13	24	24	24				85.59	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.23	25	25	25				41.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											572.98	25						578.51	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	25			25			25			25			25		25
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											58.84	24	24	24				85.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											35.07	25	25	25				43.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											524.62	25						678.03	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	25			25			25			25			25		25
H2663	064	0	1	01	01	H2663_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																														
H2663	064	0	1	01	01	H2663_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																														
H2663	064	0	1	01	01	H2663_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											68.36	22	22	22				86.61	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	064	0	1	01	01	H2663_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											36.84	25	25	25				48.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	064	0	1	01	01	H2663_064_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											529.73	25						594.68	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	25			25			25			25			25		25
H2663	067	0	1	01	01	H2663_067_0	2			Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	067	0	1	01	01	H2663_067_0	2			Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	067	0	1	01	01	H2663_067_0	2			Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				84.25	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	067	0	1	01	01	H2663_067_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				42.84	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	067	0	1	01	01	H2663_067_0	2			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				564.29	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2663	097	0	1	01	01	H2663_097_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	097	0	1	01	01	H2663_097_0	2		N	Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	097	0	1	01	01	H2663_097_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				63.69	22	22	22																																				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	22	22	22										22		22
H2663	097	0	1	01	01	H2663_097_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				33.11	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H2663	097	0	1	01	01	H2663_097_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				434.86	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2663	098	0	1	01	01	H2663_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																														
H2663	098	0	1	01	01	H2663_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					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	098	0	1	01	01	H2663_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											68.18	22	22	22				86.54	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	098	0	1	01	01	H2663_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											38.59	25	25	25				46.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	098	0	1	01	01	H2663_098_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											509.95	25						749.99	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	25			25			25			25			25		25
H2663	099	0	1	01	01	H2663_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2663	099	0	1	01	01	H2663_099_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H2663	099	0	1	01	01	H2663_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				89.19	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		35.00	25	25	25				25	25	25				25		25
H2663	099	0	1	01	01	H2663_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				38.54	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	25	25	25				25	25	25				25		25
H2663	099	0	1	01	01	H2663_099_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				503.21	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2663	100	0	1	01	01	H2663_100_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	100	0	1	01	01	H2663_100_0	2			Generic	4	01	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	100	0	1	01	01	H2663_100_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.10	22	22	22				86.38	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	100	0	1	01	01	H2663_100_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.01	25	25	25				46.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	100	0	1	01	01	H2663_100_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											516.56	25						750.80	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	25			25			25			25			25		25
H2663	102	0	1	01	01	H2663_102_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	102	0	1	01	01	H2663_102_0	2			Generic	4	01	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	102	0	1	01	01	H2663_102_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.18	22	22	22				86.54	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H2663	102	0	1	01	01	H2663_102_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.59	25	25	25				46.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	102	0	1	01	01	H2663_102_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											509.95	25						749.99	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	25			25			25			25			25		25
H2663	103	0	1	02	01	H2663_103_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	103	0	1	02	01	H2663_103_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	103	0	1	02	01	H2663_103_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.74	24	24	24				90.03	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H2663	103	0	1	02	01	H2663_103_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.02	25	25	25				46.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2663	103	0	1	02	01	H2663_103_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.55	25						679.79	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	25			25			25			25			25		25
H2686	004	1	1	04	01	H2686_004_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	004	1	1	04	01	H2686_004_1	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	25	25	25				25	25	25				25		25
H2686	004	1	1	04	01	H2686_004_1	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2686	004	1	1	04	01	H2686_004_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				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	25	25	25				25	25	25				25		25
H2686	004	1	1	04	01	H2686_004_1	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	25						25						25		25
H2686	004	3	1	04	01	H2686_004_3	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	0	0	0				0	0	0				0		0
H2686	004	3	1	04	01	H2686_004_3	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	25	25	25				25	25	25				25		25
H2686	004	3	1	04	01	H2686_004_3	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				67.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2686	004	3	1	04	01	H2686_004_3	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2686	004	3	1	04	01	H2686_004_3	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	25						25						25		25
H2686	005	1	1	04	01	H2686_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	005	1	1	04	01	H2686_005_1	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	25	25	25				25	25	25				25		25
H2686	005	1	1	04	01	H2686_005_1	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				68.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2686	005	1	1	04	01	H2686_005_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				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	25	25	25				25	25	25				25		25
H2686	005	1	1	04	01	H2686_005_1	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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				68.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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	25	25	25				25	25	25				25		25
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	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2686	006	1	1	04	01	H2686_006_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	006	1	1	04	01	H2686_006_1	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	25	25	25				25	25	25				25		25
H2686	006	1	1	04	01	H2686_006_1	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				64.00	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		35.00	23	23	23				23	23	23				23		23
H2686	006	1	1	04	01	H2686_006_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				83.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2686	006	1	1	04	01	H2686_006_1	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	25						25						25		25
H2686	006	2	1	04	01	H2686_006_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	006	2	1	04	01	H2686_006_2	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	25	25	25				25	25	25				25		25
H2686	006	2	1	04	01	H2686_006_2	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				64.00	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		35.00	23	23	23				23	23	23				23		23
H2686	006	2	1	04	01	H2686_006_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				83.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2686	006	2	1	04	01	H2686_006_2	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	25						25						25		25
H2686	008	0	1	04	01	H2686_008_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	0	0	0				0	0	0				0		0
H2686	008	0	1	04	01	H2686_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	008	0	1	04	01	H2686_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				33.00	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	19	19	19				19	19	19				19		19
H2686	008	0	1	04	01	H2686_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				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	25	25	25				25	25	25				25		25
H2686	008	0	1	04	01	H2686_008_0	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	25						25						25		25
H2686	009	0	1	04	01	H2686_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	009	0	1	04	01	H2686_009_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	25	25	25				25	25	25				25		25
H2686	009	0	1	04	01	H2686_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				39.00	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	21	21	21				21	21	21				21		21
H2686	009	0	1	04	01	H2686_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				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	25	25	25				25	25	25				25		25
H2686	009	0	1	04	01	H2686_009_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	25						25						25		25
H2686	010	0	1	04	01	H2686_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2686	010	0	1	04	01	H2686_010_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	25	25	25				25	25	25				25		25
H2686	010	0	1	04	01	H2686_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				39.00	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	22	22	22				22	22	22				22		22
H2686	010	0	1	04	01	H2686_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				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	25	25	25				25	25	25				25		25
H2686	010	0	1	04	01	H2686_010_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	25						25						25		25
H2687	001	0	1	01	01	H2687_001_0	4			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																														
H2687	001	0	1	01	01	H2687_001_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2687	001	0	1	01	01	H2687_001_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.00	25	25	25				99.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H2687	001	0	1	01	01	H2687_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		34											19.00	30	30	30				13.00	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	25	25	25	25	25	25	25	25	25				25		25
H2687	001	0	1	01	01	H2687_001_0	4			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																														
H2694	001	0	1	04	01	H2694_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2694	001	0	1	04	01	H2694_001_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H2694	001	0	1	04	01	H2694_001_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				71.37	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H2694	001	0	1	04	01	H2694_001_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				81.61	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	25	25	25				25	25	25				25		25
H2694	001	0	1	04	01	H2694_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				644.03	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2694	002	0	1	04	01	H2694_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2694	002	0	1	04	01	H2694_002_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H2694	002	0	1	04	01	H2694_002_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				70.12	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	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H2694	002	0	1	04	01	H2694_002_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				82.77	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	25	25	25				25	25	25				25		25
H2694	002	0	1	04	01	H2694_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				644.23	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2697	001	0	1	01	01	H2697_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	0	0	0				0	0	0				0		0
H2697	001	0	1	01	01	H2697_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2697	001	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	001	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	001	0	1	01	01	H2697_001_0	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	25						25						25		25
H2697	002	0	1	01	01	H2697_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	0	0	0				0	0	0				0		0
H2697	002	0	1	01	01	H2697_002_0	6			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	25	25	25				25	25	25				25		25
H2697	002	0	1	01	01	H2697_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				56.00	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		35.00	23	23	23				23	23	23				23		23
H2697	002	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	002	0	1	01	01	H2697_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				58.00	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	22	22	22				22	22	22				22		22
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H2697	004	0	1	01	01	H2697_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	0	0	0				0	0	0				0		0
H2697	004	0	1	01	01	H2697_004_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																			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	25	25	25				25	25	25				25		25
H2697	004	0	1	01	01	H2697_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				57.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2697	004	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	004	0	1	01	01	H2697_004_0	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	25						25						25		25
H2697	006	0	1	01	01	H2697_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	0	0	0				0	0	0				0		0
H2697	006	0	1	01	01	H2697_006_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	25	25	25				25	25	25				25		25
H2697	006	0	1	01	01	H2697_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				56.00	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	22	22	22				22	22	22				22		22
H2697	006	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	006	0	1	01	01	H2697_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	25						25						25		25
H2697	007	0	1	01	01	H2697_007_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	0	0	0				0	0	0				0		0
H2697	007	0	1	01	01	H2697_007_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																			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	25	25	25				25	25	25				25		25
H2697	007	0	1	01	01	H2697_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				58.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2697	007	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	007	0	1	01	01	H2697_007_0	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	25						25						25		25
H2697	009	0	1	01	01	H2697_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2697	009	0	1	01	01	H2697_009_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	25	25	25				25	25	25				25		25
H2697	009	0	1	01	01	H2697_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				56.00	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	22	22	22				22	22	22				22		22
H2697	009	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	009	0	1	01	01	H2697_009_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	25						25						25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	010	0	1	01	01	H2697_010_0	9		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	011	0	1	01	01	H2697_011_0	9		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2697	011	0	1	01	01	H2697_011_0	9		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	011	0	1	01	01	H2697_011_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	011	0	1	01	01	H2697_011_0	9		N	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	011	0	1	01	01	H2697_011_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	011	0	1	01	01	H2697_011_0	9		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	015	0	1	01	01	H2697_015_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	0	0	0				0	0	0				0		0
H2697	015	0	1	01	01	H2697_015_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2697	015	0	1	01	01	H2697_015_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				30.00	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	19	19	19				19	19	19				19		19
H2697	015	0	1	01	01	H2697_015_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				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	25	25	25				25	25	25				25		25
H2697	015	0	1	01	01	H2697_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2697	016	0	1	01	01	H2697_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2697	016	0	1	01	01	H2697_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2697	016	0	1	01	01	H2697_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	016	0	1	01	01	H2697_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H2697	016	0	1	01	01	H2697_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	016	0	1	01	01	H2697_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	017	0	1	01	01	H2697_017_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2697	017	0	1	01	01	H2697_017_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2697	017	0	1	01	01	H2697_017_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2697	017	0	1	01	01	H2697_017_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	017	0	1	01	01	H2697_017_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	017	0	1	01	01	H2697_017_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	018	0	1	01	01	H2697_018_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2697	018	0	1	01	01	H2697_018_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2697	018	0	1	01	01	H2697_018_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2697	018	0	1	01	01	H2697_018_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	018	0	1	01	01	H2697_018_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	018	0	1	01	01	H2697_018_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	019	0	1	01	01	H2697_019_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	0	0	0				0	0	0				0		0
H2697	019	0	1	01	01	H2697_019_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2697	019	0	1	01	01	H2697_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				30.00	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	19	19	19				19	19	19				19		19
H2697	019	0	1	01	01	H2697_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				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	25	25	25				25	25	25				25		25
H2697	019	0	1	01	01	H2697_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2697	020	0	1	01	01	H2697_020_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2697	020	0	1	01	01	H2697_020_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H2697	020	0	1	01	01	H2697_020_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H2697	020	0	1	01	01	H2697_020_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2697	020	0	1	01	01	H2697_020_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2697	020	0	1	01	01	H2697_020_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2697	022	0	1	01	01	H2697_022_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	0	0	0				0	0	0				0		0
H2697	022	0	1	01	01	H2697_022_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2697	022	0	1	01	01	H2697_022_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				30.00	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	19	19	19				19	19	19				19		19
H2697	022	0	1	01	01	H2697_022_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				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	25	25	25				25	25	25				25		25
H2697	022	0	1	01	01	H2697_022_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2704	015	0	1	01	01	H2704_015_0	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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2704	015	0	1	01	01	H2704_015_0	4		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	0	0	0				0	0	0				0		0
H2704	015	0	1	01	01	H2704_015_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				53.00	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	0	0	0				0	0	0				0		0
H2704	015	0	1	01	01	H2704_015_0	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				68.00	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	0	0	0				0	0	0				0		0
H2704	015	0	1	01	01	H2704_015_0	4		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2704	015	0	1	01	01	H2704_015_0	4		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																														
H2704	016	0	1	01	01	H2704_016_0	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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2704	016	0	1	01	01	H2704_016_0	4		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	0	0	0				0	0	0				0		0
H2704	016	0	1	01	01	H2704_016_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				43.00	17	17	17																		17	17	17															17			17								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	0	0	0				0	0	0				0		0
H2704	016	0	1	01	01	H2704_016_0	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				64.00	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	0	0	0				0	0	0				0		0
H2704	016	0	1	01	01	H2704_016_0	4		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31					25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2704	016	0	1	01	01	H2704_016_0	4		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																														
H2715	003	0	1	01	01	H2715_003_0	8			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	8			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	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	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	25	25	25				25	25	25				25		25
H2715	003	0	1	01	01	H2715_003_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				77.25	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		35.00	25	25	25				25	25	25				25		25
H2715	003	0	1	01	01	H2715_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				559.64	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2715	003	0	1	01	01	H2715_003_0	8			Select Care Drugs	4	01	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																														
H2715	006	1	1	01	01	H2715_006_1	9		N	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																														
H2715	006	1	1	01	01	H2715_006_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.69	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2715	006	1	1	01	01	H2715_006_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.28	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		35.00	20	20	20				20	20	20				20		20
H2715	006	1	1	01	01	H2715_006_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.58	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		35.00	25	25	25				25	25	25				25		25
H2715	006	1	1	01	01	H2715_006_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				482.50	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	25						25						25		25
H2715	006	1	1	01	01	H2715_006_1	9		N	Select Care Drugs	4	01	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																														
H2715	006	2	1	01	01	H2715_006_2	9		N	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																														
H2715	006	2	1	01	01	H2715_006_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.69	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2715	006	2	1	01	01	H2715_006_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.28	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		35.00	20	20	20				20	20	20				20		20
H2715	006	2	1	01	01	H2715_006_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.58	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		35.00	25	25	25				25	25	25				25		25
H2715	006	2	1	01	01	H2715_006_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				482.50	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	25						25						25		25
H2715	006	2	1	01	01	H2715_006_2	9		N	Select Care Drugs	4	01	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																														
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	25	25	25	25	25	25			25			25	25		25
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	25	25	25	25	25	25			25			25	25		25
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											96.27	30	30	30				97.83	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			70.00			70.00	35.00		35.00	25	25	25	25	25	25			25			25	25		25
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	25			25									25		25
H2752	003	0	1	01	01	H2752_003_0	6		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H2752	003	0	1	01	01	H2752_003_0	6		N	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					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	7.00	14.00	21.00	12.00	24.00	36.00	7.00	14.00	0.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H2752	003	0	1	01	01	H2752_003_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											21.95	23	23	23				22.61	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H2752	003	0	1	01	01	H2752_003_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											52.28	25	25	25				56.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H2752	003	0	1	01	01	H2752_003_0	6		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											492.39	25						481.97	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	25			25			25			25			25		25
H2775	106	0	1	04	01	H2775_106_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2775	106	0	1	04	01	H2775_106_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2775	106	0	1	04	01	H2775_106_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											115.70	25	25	25				115.70	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	106	0	1	04	01	H2775_106_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.69	38	38	38				97.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	106	0	1	04	01	H2775_106_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	106	0	1	04	01	H2775_106_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2775	109	0	1	04	01	H2775_109_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2775	109	0	1	04	01	H2775_109_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											110.42	25	25	25				110.42	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	109	0	1	04	01	H2775_109_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											65.23	36	36	36				65.23	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	109	0	1	04	01	H2775_109_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	109	0	1	04	01	H2775_109_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2775	111	0	1	04	01	H2775_111_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2775	111	0	1	04	01	H2775_111_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											118.30	25	25	25				118.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	111	0	1	04	01	H2775_111_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.42	34	34	34				98.42	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	111	0	1	04	01	H2775_111_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	111	0	1	04	01	H2775_111_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	112	0	1	04	01	H2775_112_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	112	0	1	04	01	H2775_112_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	112	0	1	04	01	H2775_112_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.79	20	20	20				86.79	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H2775	112	0	1	04	01	H2775_112_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											43.19	32	32	32				43.19	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	112	0	1	04	01	H2775_112_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	112	0	1	04	01	H2775_112_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	113	0	1	04	01	H2775_113_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.21	25	25	25				104.21	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	113	0	1	04	01	H2775_113_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	113	0	1	04	01	H2775_113_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	115	0	1	04	01	H2775_115_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	115	0	1	04	01	H2775_115_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	115	0	1	04	01	H2775_115_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											102.42	25	25	25				102.42	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	115	0	1	04	01	H2775_115_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2775	115	0	1	04	01	H2775_115_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2775	115	0	1	04	01	H2775_115_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2802	001	0	1	02	01	H2802_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	001	0	1	02	01	H2802_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	001	0	1	02	01	H2802_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2802	001	0	1	02	01	H2802_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	001	0	1	02	01	H2802_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				378.00	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	25						25			25			25		25
H2802	007	0	1	02	01	H2802_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	007	0	1	02	01	H2802_007_0	4			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																														
H2802	007	0	1	02	01	H2802_007_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2802	007	0	1	02	01	H2802_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				78.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	007	0	1	02	01	H2802_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				408.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	008	0	1	02	01	H2802_008_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	008	0	1	02	01	H2802_008_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	008	0	1	02	01	H2802_008_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	008	0	1	02	01	H2802_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	008	0	1	02	01	H2802_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				398.00	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	25						25			25			25		25
H2802	010	0	1	02	01	H2802_010_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	010	0	1	02	01	H2802_010_0	4			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																														
H2802	010	0	1	02	01	H2802_010_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H2802	010	0	1	02	01	H2802_010_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				89.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	010	0	1	02	01	H2802_010_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	012	0	1	02	01	H2802_012_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	012	0	1	02	01	H2802_012_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	012	0	1	02	01	H2802_012_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2802	012	0	1	02	01	H2802_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	012	0	1	02	01	H2802_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				316.00	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	25						25			25			25		25
H2802	024	0	1	02	01	H2802_024_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	024	0	1	02	01	H2802_024_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	024	0	1	02	01	H2802_024_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	024	0	1	02	01	H2802_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				92.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	024	0	1	02	01	H2802_024_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				377.00	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	25						25			25			25		25
H2802	025	0	1	02	01	H2802_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	025	0	1	02	01	H2802_025_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	025	0	1	02	01	H2802_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	025	0	1	02	01	H2802_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	025	0	1	02	01	H2802_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				412.00	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	25						25			25			25		25
H2802	028	0	1	02	01	H2802_028_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	028	0	1	02	01	H2802_028_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	028	0	1	02	01	H2802_028_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H2802	028	0	1	02	01	H2802_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	028	0	1	02	01	H2802_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
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	10.00		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	029	0	1	02	01	H2802_029_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2802	029	0	1	02	01	H2802_029_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				378.00	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	25						25			25			25		25
H2802	030	0	1	02	01	H2802_030_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	030	0	1	02	01	H2802_030_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	030	0	1	02	01	H2802_030_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	030	0	1	02	01	H2802_030_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	030	0	1	02	01	H2802_030_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				393.00	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	25						25			25			25		25
H2802	031	0	1	02	01	H2802_031_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	031	0	1	02	01	H2802_031_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	031	0	1	02	01	H2802_031_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	031	0	1	02	01	H2802_031_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	031	0	1	02	01	H2802_031_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				404.00	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	25						25			25			25		25
H2802	032	0	1	02	01	H2802_032_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	032	0	1	02	01	H2802_032_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	032	0	1	02	01	H2802_032_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	032	0	1	02	01	H2802_032_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	032	0	1	02	01	H2802_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H2802	033	0	1	02	01	H2802_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	033	0	1	02	01	H2802_033_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	033	0	1	02	01	H2802_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	033	0	1	02	01	H2802_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	033	0	1	02	01	H2802_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H2802	034	0	1	02	01	H2802_034_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	034	0	1	02	01	H2802_034_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	034	0	1	02	01	H2802_034_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H2802	034	0	1	02	01	H2802_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	034	0	1	02	01	H2802_034_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H2802	035	0	1	02	01	H2802_035_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	035	0	1	02	01	H2802_035_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	035	0	1	02	01	H2802_035_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	035	0	1	02	01	H2802_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	035	0	1	02	01	H2802_035_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				392.00	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	25						25			25			25		25
H2802	041	0	1	02	01	H2802_041_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	041	0	1	02	01	H2802_041_0	4			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																														
H2802	041	0	1	02	01	H2802_041_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H2802	041	0	1	02	01	H2802_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				76.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	041	0	1	02	01	H2802_041_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	044	0	1	02	01	H2802_044_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2802	044	0	1	02	01	H2802_044_0	4		N	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																														
H2802	044	0	1	02	01	H2802_044_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H2802	044	0	1	02	01	H2802_044_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	044	0	1	02	01	H2802_044_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				372.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	048	0	1	02	01	H2802_048_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	048	0	1	02	01	H2802_048_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	048	0	1	02	01	H2802_048_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	048	0	1	02	01	H2802_048_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	048	0	1	02	01	H2802_048_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				349.00	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	25						25			25			25		25
H2802	049	0	1	02	01	H2802_049_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	049	0	1	02	01	H2802_049_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	049	0	1	02	01	H2802_049_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	049	0	1	02	01	H2802_049_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	049	0	1	02	01	H2802_049_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				410.00	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	25						25			25			25		25
H2802	052	0	1	02	01	H2802_052_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	052	0	1	02	01	H2802_052_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	052	0	1	02	01	H2802_052_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	052	0	1	02	01	H2802_052_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	052	0	1	02	01	H2802_052_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H2802	053	0	1	02	01	H2802_053_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2802	053	0	1	02	01	H2802_053_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	053	0	1	02	01	H2802_053_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H2802	053	0	1	02	01	H2802_053_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H2802	053	0	1	02	01	H2802_053_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				358.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	054	0	1	02	01	H2802_054_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	054	0	1	02	01	H2802_054_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	054	0	1	02	01	H2802_054_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	054	0	1	02	01	H2802_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	054	0	1	02	01	H2802_054_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H2802	055	0	1	02	01	H2802_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																														
H2802	055	0	1	02	01	H2802_055_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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	055	0	1	02	01	H2802_055_0	6			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2802	055	0	1	02	01	H2802_055_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	055	0	1	02	01	H2802_055_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				361.00	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	25						25			25			25		25
H2802	056	0	1	02	01	H2802_056_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	056	0	1	02	01	H2802_056_0	4			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																														
H2802	056	0	1	02	01	H2802_056_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H2802	056	0	1	02	01	H2802_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				80.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	056	0	1	02	01	H2802_056_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	058	0	1	02	01	H2802_058_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	058	0	1	02	01	H2802_058_0	4			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																														
H2802	058	0	1	02	01	H2802_058_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H2802	058	0	1	02	01	H2802_058_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				82.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	058	0	1	02	01	H2802_058_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				342.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	059	0	1	02	01	H2802_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	059	0	1	02	01	H2802_059_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	059	0	1	02	01	H2802_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2802	059	0	1	02	01	H2802_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	059	0	1	02	01	H2802_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H2802	060	0	1	02	01	H2802_060_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	060	0	1	02	01	H2802_060_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	8.00		24.00																					24.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	060	0	1	02	01	H2802_060_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				38.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H2802	060	0	1	02	01	H2802_060_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				69.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	060	0	1	02	01	H2802_060_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	061	0	1	02	01	H2802_061_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	061	0	1	02	01	H2802_061_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	8.00		24.00																					24.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	061	0	1	02	01	H2802_061_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				35.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	15		15						15				15		15
H2802	061	0	1	02	01	H2802_061_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				64.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	061	0	1	02	01	H2802_061_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				344.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	063	0	1	02	01	H2802_063_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	063	0	1	02	01	H2802_063_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	4.00		12.00																					12.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	063	0	1	02	01	H2802_063_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				35.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	15		15						15				15		15
H2802	063	0	1	02	01	H2802_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				68.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	063	0	1	02	01	H2802_063_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				384.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	064	0	1	02	01	H2802_064_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H2802	064	0	1	02	01	H2802_064_0	4		N	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																														
H2802	064	0	1	02	01	H2802_064_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H2802	064	0	1	02	01	H2802_064_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	064	0	1	02	01	H2802_064_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				355.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	068	0	1	02	01	H2802_068_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	068	0	1	02	01	H2802_068_0	4			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																														
H2802	068	0	1	02	01	H2802_068_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H2802	068	0	1	02	01	H2802_068_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				63.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	068	0	1	02	01	H2802_068_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	070	0	1	02	01	H2802_070_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	070	0	1	02	01	H2802_070_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	070	0	1	02	01	H2802_070_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H2802	070	0	1	02	01	H2802_070_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	070	0	1	02	01	H2802_070_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H2802	071	0	1	02	01	H2802_071_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	071	0	1	02	01	H2802_071_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	071	0	1	02	01	H2802_071_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H2802	071	0	1	02	01	H2802_071_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	071	0	1	02	01	H2802_071_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	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	25						25			25			25		25
H2802	072	0	1	02	01	H2802_072_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	072	0	1	02	01	H2802_072_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	072	0	1	02	01	H2802_072_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2802	072	0	1	02	01	H2802_072_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	072	0	1	02	01	H2802_072_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				408.00	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	25						25			25			25		25
H2802	073	0	1	02	01	H2802_073_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	073	0	1	02	01	H2802_073_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	073	0	1	02	01	H2802_073_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H2802	073	0	1	02	01	H2802_073_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	073	0	1	02	01	H2802_073_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
H2802	074	0	1	02	01	H2802_074_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	074	0	1	02	01	H2802_074_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	074	0	1	02	01	H2802_074_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H2802	074	0	1	02	01	H2802_074_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	074	0	1	02	01	H2802_074_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
H2802	075	0	1	02	01	H2802_075_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	075	0	1	02	01	H2802_075_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	075	0	1	02	01	H2802_075_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H2802	075	0	1	02	01	H2802_075_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	075	0	1	02	01	H2802_075_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				349.00	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	25						25			25			25		25
H2802	076	0	1	02	01	H2802_076_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	076	0	1	02	01	H2802_076_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	076	0	1	02	01	H2802_076_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H2802	076	0	1	02	01	H2802_076_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H2802	076	0	1	02	01	H2802_076_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				399.00	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	25						25			25			25		25
H2802	078	0	1	02	01	H2802_078_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	078	0	1	02	01	H2802_078_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	8.00		24.00																					24.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	078	0	1	02	01	H2802_078_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				36.00	15		15																				15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	15		15						15				15		15
H2802	078	0	1	02	01	H2802_078_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				70.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	078	0	1	02	01	H2802_078_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				365.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	079	0	1	02	01	H2802_079_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2802	079	0	1	02	01	H2802_079_0	4			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																														
H2802	079	0	1	02	01	H2802_079_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H2802	079	0	1	02	01	H2802_079_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2802	079	0	1	02	01	H2802_079_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H2816	013	0	1	09	04	H2816_013_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2816	013	0	1	09	04	H2816_013_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2816	013	0	1	09	04	H2816_013_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.31	25	25	25				100.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2816	013	0	1	09	04	H2816_013_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.73	38	38	38				68.87	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2816	013	0	1	09	04	H2816_013_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2816	013	0	1	09	04	H2816_013_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2816	019	0	1	09	04	H2816_019_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2816	019	0	1	09	04	H2816_019_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											94.07	25	25	25				94.07	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2816	019	0	1	09	04	H2816_019_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.78	39	39	39				67.99	38	38	38											39	39					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2816	019	0	1	09	04	H2816_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2816	019	0	1	09	04	H2816_019_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2819	001	0	1	01	01	H2819_001_0	8		N	Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2819	001	0	1	01	01	H2819_001_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				2	2			100				30		31				68.21	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	25	25	25						25				25		25
H2819	001	0	1	01	01	H2819_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				2	2			100				30		31				82.50	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	25	25	25						25				25		25
H2819	001	0	1	01	01	H2819_001_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				486.82	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2836	006	0	1	04	01	H2836_006_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2836	006	0	1	04	01	H2836_006_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2836	006	0	1	04	01	H2836_006_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				75.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2836	006	0	1	04	01	H2836_006_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				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2836	006	0	1	04	01	H2836_006_0	6		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																														
H2836	006	0	1	04	01	H2836_006_0	6		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																														
H2836	007	0	1	04	01	H2836_007_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2836	007	0	1	04	01	H2836_007_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2836	007	0	1	04	01	H2836_007_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				80.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2836	007	0	1	04	01	H2836_007_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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2836	007	0	1	04	01	H2836_007_0	6		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																														
H2836	007	0	1	04	01	H2836_007_0	6		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																														
H2845	001	0	1	04	01	H2845_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	0	0	0				0	0	0				0		0
H2845	001	0	1	04	01	H2845_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2845	001	0	1	04	01	H2845_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				33.00	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	19	19	19				19	19	19				19		19
H2845	001	0	1	04	01	H2845_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2845	001	0	1	04	01	H2845_001_0	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	25						25						25		25
H2845	002	0	1	04	01	H2845_002_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	0	0	0				0	0	0				0		0
H2845	002	0	1	04	01	H2845_002_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	25	25	25				25	25	25				25		25
H2845	002	0	1	04	01	H2845_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				39.00	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	21	21	21				21	21	21				21		21
H2845	002	0	1	04	01	H2845_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				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	25	25	25				25	25	25				25		25
H2845	002	0	1	04	01	H2845_002_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	25						25						25		25
H2845	003	0	1	04	01	H2845_003_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H2845	003	0	1	04	01	H2845_003_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2845	003	0	1	04	01	H2845_003_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				46.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2845	003	0	1	04	01	H2845_003_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2845	003	0	1	04	01	H2845_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2845	003	0	1	04	01	H2845_003_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2845	005	0	1	04	01	H2845_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H2845	005	0	1	04	01	H2845_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2845	005	0	1	04	01	H2845_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				33.00	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	19	19	19				19	19	19				19		19
H2845	005	0	1	04	01	H2845_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				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	25	25	25				25	25	25				25		25
H2845	005	0	1	04	01	H2845_005_0	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	25						25						25		25
H2845	006	0	1	04	01	H2845_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	0	0	0				0	0	0				0		0
H2845	006	0	1	04	01	H2845_006_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	25	25	25				25	25	25				25		25
H2845	006	0	1	04	01	H2845_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				39.00	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	21	21	21				21	21	21				21		21
H2845	006	0	1	04	01	H2845_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				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	25	25	25				25	25	25				25		25
H2845	006	0	1	04	01	H2845_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	25						25						25		25
H2845	008	0	1	04	01	H2845_008_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2845	008	0	1	04	01	H2845_008_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2845	008	0	1	04	01	H2845_008_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2845	008	0	1	04	01	H2845_008_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H2845	008	0	1	04	01	H2845_008_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2845	008	0	1	04	01	H2845_008_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2845	009	0	1	04	01	H2845_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2845	009	0	1	04	01	H2845_009_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2845	009	0	1	04	01	H2845_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H2845	009	0	1	04	01	H2845_009_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H2845	009	0	1	04	01	H2845_009_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2845	009	0	1	04	01	H2845_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2845	010	0	1	04	01	H2845_010_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2845	010	0	1	04	01	H2845_010_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2845	010	0	1	04	01	H2845_010_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H2845	010	0	1	04	01	H2845_010_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H2845	010	0	1	04	01	H2845_010_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2845	010	0	1	04	01	H2845_010_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2875	001	0	1	02	01	H2875_001_0	3		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	0		0				25		25	0		0	0		0
H2875	001	0	1	02	01	H2875_001_0	3		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	0		0				25		25	0		0	0		0
H2875	001	0	1	02	01	H2875_001_0	3		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	001	0	1	02	01	H2875_001_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	001	0	1	02	01	H2875_001_0	3		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	25						25			25			25		25
H2875	002	0	1	02	01	H2875_002_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	0		0				25		25	0		0	0		0
H2875	002	0	1	02	01	H2875_002_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	0		0				25		25	0		0	0		0
H2875	002	0	1	02	01	H2875_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	002	0	1	02	01	H2875_002_0	4		N	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	25		25				25		25	25		25	25		25
H2875	002	0	1	02	01	H2875_002_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	25						25			25			25		25
H2875	003	0	1	01	01	H2875_003_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	0		0				25		25	0		0	0		0
H2875	003	0	1	01	01	H2875_003_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	0		0				25		25	0		0	0		0
H2875	003	0	1	01	01	H2875_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	003	0	1	01	01	H2875_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	003	0	1	01	01	H2875_003_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	25						25			25			25		25
H2875	004	0	1	01	01	H2875_004_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	0		0				25		25	0		0	0		0
H2875	004	0	1	01	01	H2875_004_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	0		0				25		25	0		0	0		0
H2875	004	0	1	01	01	H2875_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	004	0	1	01	01	H2875_004_0	4		N	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	25		25				25		25	25		25	25		25
H2875	004	0	1	01	01	H2875_004_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	25						25			25			25		25
H2875	005	0	1	01	01	H2875_005_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	0		0				25		25	0		0	0		0
H2875	005	0	1	01	01	H2875_005_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	0		0				25		25	0		0	0		0
H2875	005	0	1	01	01	H2875_005_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	005	0	1	01	01	H2875_005_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H2875	005	0	1	01	01	H2875_005_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	25						25			25			25		25
H2875	006	0	1	02	01	H2875_006_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	0		0				25		25	0		0	0		0
H2875	006	0	1	02	01	H2875_006_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	0		0				25		25	0		0	0		0
H2875	006	0	1	02	01	H2875_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	006	0	1	02	01	H2875_006_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H2875	006	0	1	02	01	H2875_006_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	25						25			25			25		25
H2915	002	0	1	02	01	H2915_002_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	002	0	1	02	01	H2915_002_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	002	0	1	02	01	H2915_002_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.54	20	20	20				83.54	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H2915	002	0	1	02	01	H2915_002_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											37.38	32	32	32				37.38	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	002	0	1	02	01	H2915_002_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	002	0	1	02	01	H2915_002_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	02	01	H2915_003_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H2915	003	0	1	02	01	H2915_003_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H2915	003	0	1	02	01	H2915_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.20	25	25	25				120.20	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	003	0	1	02	01	H2915_003_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.21	36	36	36				73.12	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	003	0	1	02	01	H2915_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	003	0	1	02	01	H2915_003_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	02	01	H2915_011_0	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	011	0	1	02	01	H2915_011_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	011	0	1	02	01	H2915_011_0	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.18	25	25	25				104.18	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	011	0	1	02	01	H2915_011_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	011	0	1	02	01	H2915_011_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	011	0	1	02	01	H2915_011_0	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	018	0	1	02	01	H2915_018_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	018	0	1	02	01	H2915_018_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	018	0	1	02	01	H2915_018_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.83	25	25	25				98.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	018	0	1	02	01	H2915_018_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H2915	018	0	1	02	01	H2915_018_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2915	018	0	1	02	01	H2915_018_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	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	0	0	0				0	0	0				0		0
H2923	001	0	1	01	01	H2923_001_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																			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	25	25	25				25	25	25				25		25
H2923	001	0	1	01	01	H2923_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				60.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2923	001	0	1	01	01	H2923_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				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	25	25	25				25	25	25				25		25
H2923	001	0	1	01	01	H2923_001_0	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	25						25						25		25
H2923	003	0	1	01	01	H2923_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	0	0	0				0	0	0				0		0
H2923	003	0	1	01	01	H2923_003_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	0	0	0				0	0	0				0		0
H2923	003	0	1	01	01	H2923_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				40.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H2923	003	0	1	01	01	H2923_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				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	25	25	25				25	25	25				25		25
H2923	003	0	1	01	01	H2923_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	25						25						25		25
H2923	004	0	1	01	01	H2923_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2923	004	0	1	01	01	H2923_004_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	25	25	25				25	25	25				25		25
H2923	004	0	1	01	01	H2923_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				39.00	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	21	21	21				21	21	21				21		21
H2923	004	0	1	01	01	H2923_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				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	25	25	25				25	25	25				25		25
H2923	004	0	1	01	01	H2923_004_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	25						25						25		25
H2923	005	0	1	01	01	H2923_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H2923	005	0	1	01	01	H2923_005_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	25	25	25				25	25	25				25		25
H2923	005	0	1	01	01	H2923_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				37.00	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	22	22	22				22	22	22				22		22
H2923	005	0	1	01	01	H2923_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				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		35.00	25	25	25				25	25	25				25		25
H2923	005	0	1	01	01	H2923_005_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	25						25						25		25
H2923	006	0	1	01	01	H2923_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	0	0	0				0	0	0				0		0
H2923	006	0	1	01	01	H2923_006_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	25	25	25				25	25	25				25		25
H2923	006	0	1	01	01	H2923_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				37.00	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	22	22	22				22	22	22				22		22
H2923	006	0	1	01	01	H2923_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				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		35.00	25	25	25				25	25	25				25		25
H2923	006	0	1	01	01	H2923_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	25						25						25		25
H2923	009	0	1	01	01	H2923_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H2923	009	0	1	01	01	H2923_009_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H2923	009	0	1	01	01	H2923_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H2923	009	0	1	01	01	H2923_009_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H2923	009	0	1	01	01	H2923_009_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H2923	009	0	1	01	01	H2923_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2942	001	0	1	01	01	H2942_001_0	5			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	5			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	25	25	25	25	25	25			25				25		25
H2942	001	0	1	01	01	H2942_001_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					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	25	25	25	25	25	25			25				25		25
H2942	001	0	1	01	01	H2942_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					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	25	25	25	25	25	25			25				25		25
H2942	001	0	1	01	01	H2942_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1000.00	30						1000.00	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H2942	001	0	1	01	01	H2942_001_0	5			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	0	0	0	0	0	0			0				0		0
H2942	002	0	1	01	01	H2942_002_0	5			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	002	0	1	01	01	H2942_002_0	5			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	25	25	25	25	25	25			25				25		25
H2942	002	0	1	01	01	H2942_002_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					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	25	25	25	25	25	25			25				25		25
H2942	002	0	1	01	01	H2942_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					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	25	25	25	25	25	25			25				25		25
H2942	002	0	1	01	01	H2942_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1000.00	28						1000.00	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H2942	002	0	1	01	01	H2942_002_0	5			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	0	0	0	0	0	0			0				0		0
H2942	003	0	1	01	01	H2942_003_0	5			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	003	0	1	01	01	H2942_003_0	5			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	25	25	25	25	25	25			25				25		25
H2942	003	0	1	01	01	H2942_003_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					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	25	25	25	25	25	25			25				25		25
H2942	003	0	1	01	01	H2942_003_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					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	25	25	25	25	25	25			25				25		25
H2942	003	0	1	01	01	H2942_003_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1000.00	28						1000.00	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H2942	003	0	1	01	01	H2942_003_0	5			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	0	0	0	0	0	0			0				0		0
H2960	012	0	1	01	01	H2960_012_0	4			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	4			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	4			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	25	25	25					25	25				25		25
H2960	012	0	1	01	01	H2960_012_0	4			Non-Preferred Drug	4	10	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				99.23	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	25	25	25					25	25				25		25
H2960	012	0	1	01	01	H2960_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2960	012	0	1	01	01	H2960_012_0	4			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	4			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	4			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	4			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	25	25	25					25	25				25		25
H2960	018	0	1	01	01	H2960_018_0	4			Non-Preferred Drug	4	10	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				82.70	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	25	25	25					25	25				25		25
H2960	018	0	1	01	01	H2960_018_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	35.00												35.00		35.00	25												25		25
H2960	018	0	1	01	01	H2960_018_0	4			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	25	25	25					25	25				25		25
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				99.73	47	47	47																			47	47															47			47								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	25	25	25					25	25				25		25
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	25												25		25
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	25	25	25					25	25				25		25
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				97.50	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	25	25	25					25	25				25		25
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	25												25		25
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	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 Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	001	0	1	01	01	H2962_001_0	13			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	13			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	25		25						25				25		25
H2962	001	0	1	01	01	H2962_001_0	13			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				49.74	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2962	001	0	1	01	01	H2962_001_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				119.51	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2962	021	0	1	01	01	H2962_021_0	16			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	0		0						0				0		0
H2962	021	0	1	01	01	H2962_021_0	16			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	16			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	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H2962	021	0	1	01	01	H2962_021_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				33.22	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	021	0	1	01	01	H2962_021_0	16			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				134.72	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	021	0	1	01	01	H2962_021_0	16			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	25		25						25				25		25
H2962	023	0	1	01	01	H2962_023_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	023	0	1	01	01	H2962_023_0	14			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	14			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	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H2962	023	0	1	01	01	H2962_023_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				46.53	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	023	0	1	01	01	H2962_023_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				132.45	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	023	0	1	01	01	H2962_023_0	14			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	25		25						25				25		25
H2962	025	0	1	01	01	H2962_025_0	16			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	0		0						0				0		0
H2962	025	0	1	01	01	H2962_025_0	16			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	16			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	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H2962	025	0	1	01	01	H2962_025_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				43.20	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	025	0	1	01	01	H2962_025_0	16			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				136.33	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	025	0	1	01	01	H2962_025_0	16			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	25		25						25				25		25
H2962	026	0	1	01	01	H2962_026_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	026	0	1	01	01	H2962_026_0	14			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	14			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	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H2962	026	0	1	01	01	H2962_026_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				37.57	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	026	0	1	01	01	H2962_026_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				157.38	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	026	0	1	01	01	H2962_026_0	14			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	25		25						25				25		25
H2962	028	0	1	01	01	H2962_028_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 Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	028	0	1	01	01	H2962_028_0	13			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	13			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	25		25						25				25		25
H2962	028	0	1	01	01	H2962_028_0	13			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				51.98	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2962	028	0	1	01	01	H2962_028_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				148.76	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2962	029	0	1	01	01	H2962_029_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	029	0	1	01	01	H2962_029_0	14			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	14			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	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H2962	029	0	1	01	01	H2962_029_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				36.70	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	029	0	1	01	01	H2962_029_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				132.75	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	029	0	1	01	01	H2962_029_0	14			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	25		25						25				25		25
H2962	033	0	1	01	01	H2962_033_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	033	0	1	01	01	H2962_033_0	14			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	14			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	30.00		90.00						60.00				30.00		30.00	25		25						25				25		25
H2962	033	0	1	01	01	H2962_033_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				36.48	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	033	0	1	01	01	H2962_033_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				140.42	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	033	0	1	01	01	H2962_033_0	14			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	25		25						25				25		25
H2962	035	0	1	01	01	H2962_035_0	11		N	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, Supplemental Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	035	0	1	01	01	H2962_035_0	11		N	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, Supplemental Drugs																														
H2962	035	0	1	01	01	H2962_035_0	11		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31				59.08	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00		105.00						70.00				35.00		35.00	25		25						25				25		25
H2962	035	0	1	01	01	H2962_035_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				38.89	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	11		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				177.63	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H2962	035	0	1	01	01	H2962_035_0	11		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	11		N	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, Supplemental Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	036	0	1	01	01	H2962_036_0	11		N	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, Supplemental Drugs																														
H2962	036	0	1	01	01	H2962_036_0	11		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31				58.83	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00		105.00						70.00				35.00		35.00	25		25						25				25		25
H2962	036	0	1	01	01	H2962_036_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				39.13	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	11		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				160.32	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00												35.00		35.00	25												25		25
H2962	036	0	1	01	01	H2962_036_0	11		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	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 Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	045	0	1	01	01	H2962_045_0	13			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	13			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	25		25						25				25		25
H2962	045	0	1	01	01	H2962_045_0	13			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				56.48	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2962	045	0	1	01	01	H2962_045_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				145.47	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2962	046	0	1	01	01	H2962_046_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 Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	046	0	1	01	01	H2962_046_0	13			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	13			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	25		25						25				25		25
H2962	046	0	1	01	01	H2962_046_0	13			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				47.75	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2962	046	0	1	01	01	H2962_046_0	13			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				121.74	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2962	047	0	1	01	01	H2962_047_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 Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	047	0	1	01	01	H2962_047_0	14			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	14			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	25		25						25				25		25
H2962	047	0	1	01	01	H2962_047_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				48.88	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H2962	047	0	1	01	01	H2962_047_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				111.56	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H2962	050	0	1	01	01	H2962_050_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	050	0	1	01	01	H2962_050_0	14			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	14			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	25.00		75.00						50.00				25.00		25.00	25		25						25				25		25
H2962	050	0	1	01	01	H2962_050_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				34.73	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	050	0	1	01	01	H2962_050_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				147.80	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	050	0	1	01	01	H2962_050_0	14			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	25		25						25				25		25
H2962	051	0	1	01	01	H2962_051_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	051	0	1	01	01	H2962_051_0	14			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	14			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	30.00		90.00						60.00				30.00		30.00	25		25						25				25		25
H2962	051	0	1	01	01	H2962_051_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				30.70	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	051	0	1	01	01	H2962_051_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				121.10	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	051	0	1	01	01	H2962_051_0	14			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	25		25						25				25		25
H2962	052	0	1	01	01	H2962_052_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 Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H2962	052	0	1	01	01	H2962_052_0	14			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	14			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	25.00		75.00						50.00				25.00		25.00	25		25						25				25		25
H2962	052	0	1	01	01	H2962_052_0	14			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				30.04	35		35																				35															35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H2962	052	0	1	01	01	H2962_052_0	14			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				117.91	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H2962	052	0	1	01	01	H2962_052_0	14			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	25		25						25				25		25
H3038	002	0	1	01	01	H3038_002_0	8		N	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																														
H3038	002	0	1	01	01	H3038_002_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				6.18	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3038	002	0	1	01	01	H3038_002_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				45.59	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	20	20	20				20	20	20				20		20
H3038	002	0	1	01	01	H3038_002_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				78.59	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		35.00	25	25	25				25	25	25				25		25
H3038	002	0	1	01	01	H3038_002_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				804.82	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	25						25						25		25
H3038	002	0	1	01	01	H3038_002_0	8		N	Select Care Drugs	4	01	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																														
H3038	004	1	1	01	01	H3038_004_1	8		N	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																														
H3038	004	1	1	01	01	H3038_004_1	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3038	004	1	1	01	01	H3038_004_1	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				40.45	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	20	20	20				20	20	20				20		20
H3038	004	1	1	01	01	H3038_004_1	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.09	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		35.00	25	25	25				25	25	25				25		25
H3038	004	1	1	01	01	H3038_004_1	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				424.05	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	25						25						25		25
H3038	004	1	1	01	01	H3038_004_1	8		N	Select Care Drugs	4	01	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																														
H3038	004	2	1	01	01	H3038_004_2	8		N	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																														
H3038	004	2	1	01	01	H3038_004_2	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3038	004	2	1	01	01	H3038_004_2	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				40.45	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	20	20	20				20	20	20				20		20
H3038	004	2	1	01	01	H3038_004_2	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.09	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		35.00	25	25	25				25	25	25				25		25
H3038	004	2	1	01	01	H3038_004_2	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				424.05	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	25						25						25		25
H3038	004	2	1	01	01	H3038_004_2	8		N	Select Care Drugs	4	01	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																														
H3038	004	3	1	01	01	H3038_004_3	8		N	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																														
H3038	004	3	1	01	01	H3038_004_3	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3038	004	3	1	01	01	H3038_004_3	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				40.45	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	20	20	20				20	20	20				20		20
H3038	004	3	1	01	01	H3038_004_3	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.09	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		35.00	25	25	25				25	25	25				25		25
H3038	004	3	1	01	01	H3038_004_3	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				424.05	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	25						25						25		25
H3038	004	3	1	01	01	H3038_004_3	8		N	Select Care Drugs	4	01	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																														
H3038	004	4	1	01	01	H3038_004_4	8		N	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																														
H3038	004	4	1	01	01	H3038_004_4	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3038	004	4	1	01	01	H3038_004_4	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				40.45	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	20	20	20				20	20	20				20		20
H3038	004	4	1	01	01	H3038_004_4	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.09	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		35.00	25	25	25				25	25	25				25		25
H3038	004	4	1	01	01	H3038_004_4	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				424.05	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	25						25						25		25
H3038	004	4	1	01	01	H3038_004_4	8		N	Select Care Drugs	4	01	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																														
H3041	001	0	1	01	01	H3041_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	0	0	0				0	0	0				0		0
H3041	001	0	1	01	01	H3041_001_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	0	0	0				0	0	0				0		0
H3041	001	0	1	01	01	H3041_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				55.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H3041	001	0	1	01	01	H3041_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				53.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3041	001	0	1	01	01	H3041_001_0	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	25						25						25		25
H3041	003	0	1	01	01	H3041_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	0	0	0				0	0	0				0		0
H3041	003	0	1	01	01	H3041_003_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	0	0	0				0	0	0				0		0
H3041	003	0	1	01	01	H3041_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				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	25	25	25				25	25	25				25		25
H3041	003	0	1	01	01	H3041_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				66.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3041	003	0	1	01	01	H3041_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	25						25						25		25
H3048	003	0	1	01	01	H3048_003_0	12			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	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H3048	003	0	1	01	01	H3048_003_0	12			Generic	4	01	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	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H3048	003	0	1	01	01	H3048_003_0	12			Preferred Brand	4	10	1	2	3	1	010		01	000		1	30														30		31	47.00																																							47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H3048	003	0	1	01	01	H3048_003_0	12			Non-Preferred Drug	4	10	1	1	4	1	010		01	000		1	30														30		31				185.47	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H3048	003	0	1	01	01	H3048_003_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				805.58	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H3071	002	0	1	01	01	H3071_002_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	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																														
H3071	002	0	1	01	01	H3071_002_0	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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3071	002	0	1	01	01	H3071_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											48.12	20	20	20				48.12	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3071	002	0	1	01	01	H3071_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											80.31	33	33	33				80.31	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3071	002	0	1	01	01	H3071_002_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											944.69	30						944.69	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H3071	002	0	1	01	01	H3071_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3080	001	0	1	01	01	H3080_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	0	0	0				0	0	0				0		0
H3080	001	0	1	01	01	H3080_001_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	0	0	0				0	0	0				0		0
H3080	001	0	1	01	01	H3080_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				57.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H3080	001	0	1	01	01	H3080_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				84.00	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		35.00	25	25	25				25	25	25				25		25
H3080	001	0	1	01	01	H3080_001_0	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	25						25						25		25
H3080	002	0	1	01	01	H3080_002_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	0	0	0				0	0	0				0		0
H3080	002	0	1	01	01	H3080_002_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	25	25	25				25	25	25				25		25
H3080	002	0	1	01	01	H3080_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				56.00	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	22	22	22				22	22	22				22		22
H3080	002	0	1	01	01	H3080_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				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	25	25	25				25	25	25				25		25
H3080	002	0	1	01	01	H3080_002_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	25						25						25		25
H3080	003	0	1	01	01	H3080_003_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H3080	003	0	1	01	01	H3080_003_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	003	0	1	01	01	H3080_003_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	003	0	1	01	01	H3080_003_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				52.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	003	0	1	01	01	H3080_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3080	003	0	1	01	01	H3080_003_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3080	004	0	1	01	01	H3080_004_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H3080	004	0	1	01	01	H3080_004_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	004	0	1	01	01	H3080_004_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	004	0	1	01	01	H3080_004_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				54.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	004	0	1	01	01	H3080_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3080	004	0	1	01	01	H3080_004_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3080	006	0	1	01	01	H3080_006_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H3080	006	0	1	01	01	H3080_006_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	006	0	1	01	01	H3080_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	006	0	1	01	01	H3080_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				57.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	006	0	1	01	01	H3080_006_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3080	006	0	1	01	01	H3080_006_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3080	007	0	1	01	01	H3080_007_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H3080	007	0	1	01	01	H3080_007_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	007	0	1	01	01	H3080_007_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				63.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	007	0	1	01	01	H3080_007_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3080	007	0	1	01	01	H3080_007_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3080	007	0	1	01	01	H3080_007_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3093	001	0	1	01	01	H3093_001_0	9		N	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																														
H3093	001	0	1	01	01	H3093_001_0	9		N	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																														
H3093	001	0	1	01	01	H3093_001_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				29.29	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	20	20	20				20	20	20				20		20
H3093	001	0	1	01	01	H3093_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				56.33	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		35.00	25	25	25				25	25	25				25		25
H3093	001	0	1	01	01	H3093_001_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				488.35	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	25						25						25		25
H3093	001	0	1	01	01	H3093_001_0	9		N	Select Care Drugs	4	01	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																														
H3093	002	0	1	01	01	H3093_002_0	9		N	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																														
H3093	002	0	1	01	01	H3093_002_0	9		N	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																														
H3093	002	0	1	01	01	H3093_002_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.26	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		35.00	20	20	20				20	20	20				20		20
H3093	002	0	1	01	01	H3093_002_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				54.94	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		35.00	25	25	25				25	25	25				25		25
H3093	002	0	1	01	01	H3093_002_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				473.28	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	25						25						25		25
H3093	002	0	1	01	01	H3093_002_0	9		N	Select Care Drugs	4	01	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																														
H3093	003	0	1	01	01	H3093_003_0	9		N	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																														
H3093	003	0	1	01	01	H3093_003_0	9		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3093	003	0	1	01	01	H3093_003_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.52	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	20	20	20				20	20	20				20		20
H3093	003	0	1	01	01	H3093_003_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				57.95	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		35.00	25	25	25				25	25	25				25		25
H3093	003	0	1	01	01	H3093_003_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				542.57	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	25						25						25		25
H3093	003	0	1	01	01	H3093_003_0	9		N	Select Care Drugs	4	01	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																														
H3093	004	0	1	01	01	H3093_004_0	9		N	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																														
H3093	004	0	1	01	01	H3093_004_0	9		N	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																														
H3093	004	0	1	01	01	H3093_004_0	9		N	Preferred Brand	4	11	1	2	3	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3093	004	0	1	01	01	H3093_004_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				48.42	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		35.00	25	25	25				25	25	25				25		25
H3093	004	0	1	01	01	H3093_004_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				548.79	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	25						25						25		25
H3093	004	0	1	01	01	H3093_004_0	9		N	Select Care Drugs	4	01	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																														
H3093	005	0	1	01	01	H3093_005_0	9		N	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																														
H3093	005	0	1	01	01	H3093_005_0	9		N	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																														
H3093	005	0	1	01	01	H3093_005_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.75	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		35.00	20	20	20				20	20	20				20		20
H3093	005	0	1	01	01	H3093_005_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				55.61	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		35.00	25	25	25				25	25	25				25		25
H3093	005	0	1	01	01	H3093_005_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				459.06	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	25						25						25		25
H3093	005	0	1	01	01	H3093_005_0	9		N	Select Care Drugs	4	01	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																														
H3113	009	0	1	02	01	H3113_009_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3113	009	0	1	02	01	H3113_009_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3113	009	0	1	02	01	H3113_009_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H3113	009	0	1	02	01	H3113_009_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	009	0	1	02	01	H3113_009_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				368.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	010	0	1	02	01	H3113_010_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3113	010	0	1	02	01	H3113_010_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3113	010	0	1	02	01	H3113_010_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H3113	010	0	1	02	01	H3113_010_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H3113	010	0	1	02	01	H3113_010_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	014	0	1	02	01	H3113_014_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3113	014	0	1	02	01	H3113_014_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3113	014	0	1	02	01	H3113_014_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H3113	014	0	1	02	01	H3113_014_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	014	0	1	02	01	H3113_014_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	016	0	1	02	01	H3113_016_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3113	016	0	1	02	01	H3113_016_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3113	016	0	1	02	01	H3113_016_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H3113	016	0	1	02	01	H3113_016_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3113	016	0	1	02	01	H3113_016_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3124	001	0	1	04	01	H3124_001_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3124	001	0	1	04	01	H3124_001_0	19			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3124	001	0	1	04	01	H3124_001_0	19			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				51.32	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3124	001	0	1	04	01	H3124_001_0	19			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.79	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	25	25	25				25	25	25				25		25
H3124	001	0	1	04	01	H3124_001_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1304.42	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3124	002	0	1	04	01	H3124_002_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3124	002	0	1	04	01	H3124_002_0	19			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																														
H3124	002	0	1	04	01	H3124_002_0	19			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	25	25	25				25	25	25				25		25
H3124	002	0	1	04	01	H3124_002_0	19			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.55	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	25	25	25				25	25	25				25		25
H3124	002	0	1	04	01	H3124_002_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1445.17	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3138	001	0	1	04	01	H3138_001_0	6			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	25	25	25	0	0	0	0	0	0				25		0
H3138	001	0	1	04	01	H3138_001_0	6			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			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H3138	001	0	1	04	01	H3138_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H3138	001	0	1	04	01	H3138_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					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3138	001	0	1	04	01	H3138_001_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	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	25	25	25	25	25	25	25	25	25				25		25
H3138	001	0	1	04	01	H3138_001_0	6			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	6			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	25	25	25	0	0	0	0	0	0				25		0
H3138	002	0	1	04	01	H3138_002_0	6			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			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H3138	002	0	1	04	01	H3138_002_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H3138	002	0	1	04	01	H3138_002_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3138	002	0	1	04	01	H3138_002_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	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	25	25	25	25	25	25	25	25	25				25		25
H3138	002	0	1	04	01	H3138_002_0	6			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	6			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	25	25	25	0	0	0	0	0	0				25		0
H3138	003	0	1	04	01	H3138_003_0	6			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			0.67	0.17	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	25	25	25	25	25	25	0	0	0				25		25
H3138	003	0	1	04	01	H3138_003_0	6			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								47.00	94.00	141.00					45.00	90.00	135.00					45.00	90.00	135.00																47.00				45.00			1.57	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	25	25	25	25	25	25	25	25	25				25		25
H3138	003	0	1	04	01	H3138_003_0	6			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3138	003	0	1	04	01	H3138_003_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	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	25	25	25	25	25	25	25	25	25				25		25
H3138	003	0	1	04	01	H3138_003_0	6			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	01	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	01	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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					12.00			12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	001	0	1	01	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											70.36	24	24	24				96.38	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	001	0	1	01	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											36.31	25	25	25				38.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	001	0	1	01	01	H3146_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											495.92	25						541.96	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	25			25			25			25			25		25
H3146	002	0	1	01	01	H3146_002_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	002	0	1	01	01	H3146_002_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	002	0	1	01	01	H3146_002_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.39	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	22	22	22				22	22	22				22		22
H3146	002	0	1	01	01	H3146_002_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				41.33	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	25	25	25				25	25	25				25		25
H3146	002	0	1	01	01	H3146_002_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				479.85	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	004	0	1	01	01	H3146_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																														
H3146	004	0	1	01	01	H3146_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																														
H3146	004	0	1	01	01	H3146_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											71.07	24	24	24				96.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	004	0	1	01	01	H3146_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											41.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	004	0	1	01	01	H3146_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											457.77	25						578.55	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	25			25			25			25			25		25
H3146	006	0	1	01	01	H3146_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																														
H3146	006	0	1	01	01	H3146_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																														
H3146	006	0	1	01	01	H3146_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											68.08	22	22	22				89.38	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	006	0	1	01	01	H3146_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											39.37	25	25	25				47.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	006	0	1	01	01	H3146_006_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											564.08	25						557.96	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	25			25			25			25			25		25
H3146	007	0	1	01	01	H3146_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																														
H3146	007	0	1	01	01	H3146_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																														
H3146	007	0	1	01	01	H3146_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											73.06	24	24	24				100.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	007	0	1	01	01	H3146_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											40.58	25	25	25				41.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	007	0	1	01	01	H3146_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											544.17	25						607.52	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	25			25			25			25			25		25
H3146	011	0	1	01	01	H3146_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																														
H3146	011	0	1	01	01	H3146_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																														
H3146	011	0	1	01	01	H3146_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											67.23	22	22	22				87.47	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	011	0	1	01	01	H3146_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											40.83	25	25	25				46.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	011	0	1	01	01	H3146_011_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											564.32	25						614.67	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	25			25			25			25			25		25
H3146	012	0	1	01	01	H3146_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																														
H3146	012	0	1	01	01	H3146_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																														
H3146	012	0	1	01	01	H3146_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											73.98	24	24	24				94.20	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	012	0	1	01	01	H3146_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											42.49	25	25	25				42.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	012	0	1	01	01	H3146_012_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											520.31	25						610.58	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	25			25			25			25			25		25
H3146	014	0	1	01	01	H3146_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																														
H3146	014	0	1	01	01	H3146_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																														
H3146	014	0	1	01	01	H3146_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											65.32	22	22	22				83.94	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	014	0	1	01	01	H3146_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											38.57	25	25	25				39.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	014	0	1	01	01	H3146_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											608.45	27						613.92	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	25			25			25			25			25		25
H3146	016	0	1	01	01	H3146_016_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	016	0	1	01	01	H3146_016_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	016	0	1	01	01	H3146_016_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.93	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	22	22	22				22	22	22				22		22
H3146	016	0	1	01	01	H3146_016_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				37.78	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	016	0	1	01	01	H3146_016_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				492.92	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	021	0	1	01	01	H3146_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																														
H3146	021	0	1	01	01	H3146_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																														
H3146	021	0	1	01	01	H3146_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											64.87	24	24	24				91.92	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	021	0	1	01	01	H3146_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											40.77	25	25	25				47.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	021	0	1	01	01	H3146_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											546.38	25						679.63	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	25			25			25			25			25		25
H3146	022	0	1	01	01	H3146_022_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	022	0	1	01	01	H3146_022_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	022	0	1	01	01	H3146_022_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.02	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	22	22	22				22	22	22				22		22
H3146	022	0	1	01	01	H3146_022_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	022	0	1	01	01	H3146_022_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				482.29	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	023	0	1	01	01	H3146_023_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	023	0	1	01	01	H3146_023_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	023	0	1	01	01	H3146_023_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				74.44	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	22	22	22				22	22	22				22		22
H3146	023	0	1	01	01	H3146_023_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	023	0	1	01	01	H3146_023_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				509.09	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	036	0	1	01	01	H3146_036_0	3			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	036	0	1	01	01	H3146_036_0	3			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	036	0	1	01	01	H3146_036_0	3			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				91.29	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	036	0	1	01	01	H3146_036_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				39.39	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	036	0	1	01	01	H3146_036_0	3			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				517.67	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	037	0	1	01	01	H3146_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																														
H3146	037	0	1	01	01	H3146_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																														
H3146	037	0	1	01	01	H3146_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											70.25	22	22	22				89.87	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	037	0	1	01	01	H3146_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											39.48	25	25	25				47.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	037	0	1	01	01	H3146_037_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											523.15	25						770.86	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	25			25			25			25			25		25
H3146	038	0	1	01	01	H3146_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																														
H3146	038	0	1	01	01	H3146_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					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	038	0	1	01	01	H3146_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											69.74	22	22	22				89.72	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	038	0	1	01	01	H3146_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											39.32	25	25	25				47.93	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	038	0	1	01	01	H3146_038_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											519.33	25						770.89	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	25			25			25			25			25		25
H3146	039	0	1	01	01	H3146_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																														
H3146	039	0	1	01	01	H3146_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																														
H3146	039	0	1	01	01	H3146_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											66.37	24	24	24				93.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	039	0	1	01	01	H3146_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											41.16	25	25	25				48.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	039	0	1	01	01	H3146_039_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											555.70	25						691.52	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	25			25			25			25			25		25
H3146	040	0	1	01	01	H3146_040_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	040	0	1	01	01	H3146_040_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																														
H3146	040	0	1	01	01	H3146_040_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.38	22	22	22				84.14	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3146	040	0	1	01	01	H3146_040_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											40.74	25	25	25				47.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	040	0	1	01	01	H3146_040_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											589.68	27						723.46	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3146	041	0	1	01	01	H3146_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																														
H3146	041	0	1	01	01	H3146_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																														
H3146	041	0	1	01	01	H3146_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											63.94	24	24	24				89.31	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	041	0	1	01	01	H3146_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											39.66	25	25	25				46.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	041	0	1	01	01	H3146_041_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											537.63	25						657.98	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	25			25			25			25			25		25
H3146	044	0	1	01	01	H3146_044_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3146	044	0	1	01	01	H3146_044_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3146	044	0	1	01	01	H3146_044_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				94.48	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	044	0	1	01	01	H3146_044_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				44.60	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3146	044	0	1	01	01	H3146_044_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				587.95	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3146	046	0	1	01	01	H3146_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																														
H3146	046	0	1	01	01	H3146_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																														
H3146	046	0	1	01	01	H3146_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											63.94	24	24	24				89.31	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	046	0	1	01	01	H3146_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											39.66	25	25	25				46.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	046	0	1	01	01	H3146_046_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											537.63	25						657.98	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	25			25			25			25			25		25
H3146	047	0	1	01	01	H3146_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																														
H3146	047	0	1	01	01	H3146_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																														
H3146	047	0	1	01	01	H3146_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											66.11	24	24	24				92.89	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3146	047	0	1	01	01	H3146_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											40.81	25	25	25				48.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3146	047	0	1	01	01	H3146_047_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											556.79	25						681.64	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	25			25			25			25			25		25
H3152	022	0	1	02	01	H3152_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																														
H3152	022	0	1	02	01	H3152_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																														
H3152	022	0	1	02	01	H3152_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											72.67	24	24	24				95.41	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3152	022	0	1	02	01	H3152_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											46.67	25	25	25				46.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3152	022	0	1	02	01	H3152_022_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											521.35	25						642.17	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	25			25			25			25			25		25
H3152	048	0	1	01	01	H3152_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																														
H3152	048	0	1	01	01	H3152_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																														
H3152	048	0	1	01	01	H3152_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											69.62	24	24	24				95.49	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3152	048	0	1	01	01	H3152_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											44.58	25	25	25				48.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3152	048	0	1	01	01	H3152_048_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											471.34	25						526.18	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	25			25			25			25			25		25
H3152	080	0	1	02	01	H3152_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																														
H3152	080	0	1	02	01	H3152_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																														
H3152	080	0	1	02	01	H3152_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											82.19	24	24	24				102.47	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3152	080	0	1	02	01	H3152_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											45.06	25	25	25				48.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3152	080	0	1	02	01	H3152_080_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											451.53	25						579.04	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	25			25			25			25			25		25
H3152	082	0	1	01	01	H3152_082_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																														
H3152	082	0	1	01	01	H3152_082_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																														
H3152	082	0	1	01	01	H3152_082_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.96	24	24	24				100.76	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3152	082	0	1	01	01	H3152_082_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											48.16	25	25	25				50.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3152	082	0	1	01	01	H3152_082_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											430.24	25						561.42	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	25			25			25			25			25		25
H3152	098	0	1	01	01	H3152_098_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																														
H3152	098	0	1	01	01	H3152_098_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																														
H3152	098	0	1	01	01	H3152_098_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.49	24	24	24				105.92	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3152	098	0	1	01	01	H3152_098_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											43.76	25	25	25				51.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3152	098	0	1	01	01	H3152_098_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											609.14	25						761.72	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	25			25			25			25			25		25
H3170	003	1	1	01	01	H3170_003_1	7			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	0	0	0				25	25	25	25	25	0	0		0
H3170	003	1	1	01	01	H3170_003_1	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	14.00	28.00	42.00																									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	25	25	25				25	25	25	25	25	0	25		25
H3170	003	1	1	01	01	H3170_003_1	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H3170	003	1	1	01	01	H3170_003_1	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	290.00				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	25	25	25				25	25	25	25	25	25	25		25
H3170	003	1	1	01	01	H3170_003_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1031.60	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3170	003	2	1	01	01	H3170_003_2	7			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	0	0	0				25	25	25	25	25	0	0		0
H3170	003	2	1	01	01	H3170_003_2	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	14.00	28.00	42.00																									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	25	25	25				25	25	25	25	25	0	25		25
H3170	003	2	1	01	01	H3170_003_2	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									47.00	94.00	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	25	25	25				25	25	25	25	25	25	25		25
H3170	003	2	1	01	01	H3170_003_2	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	290.00				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	25	25	25				25	25	25	25	25	25	25		25
H3170	003	2	1	01	01	H3170_003_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1031.60	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3186	001	0	1	04	01	H3186_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.06	0.00		0.06	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	5			Generic	4	01	1	2	2	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			0.29	0.12		0.29	0.12	0.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	001	0	1	04	01	H3186_001_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	001	0	1	04	01	H3186_001_0	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											80.58	50	50	50				81.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	001	0	1	04	01	H3186_001_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											979.78	29	29	29				942.09	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	001	0	1	04	01	H3186_001_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				34	68	102	2	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	0.00				0.00				0.00			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	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.06	0.00		0.06	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	5			Generic	4	01	1	2	2	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			0.29	0.12		0.29	0.12	0.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	002	0	1	04	01	H3186_002_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	002	0	1	04	01	H3186_002_0	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											97.44	50	50	50				98.39	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3186	002	0	1	04	01	H3186_002_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											903.25	27	27	27				873.79	27	27	27										27	27	27				27	27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3186	002	0	1	04	01	H3186_002_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				34	68	102	2	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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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											76.48	24	24	24				99.47	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.11	25	25	25				45.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											617.24	25						620.11	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	25			25			25			25			25		25
H3192	003	0	1	02	01	H3192_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																														
H3192	003	0	1	02	01	H3192_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																														
H3192	003	0	1	02	01	H3192_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											76.39	24	24	24				100.44	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3192	003	0	1	02	01	H3192_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											38.69	25	25	25				43.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3192	003	0	1	02	01	H3192_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											554.73	25						578.34	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	25			25			25			25			25		25
H3192	005	0	1	02	01	H3192_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																														
H3192	005	0	1	02	01	H3192_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																														
H3192	005	0	1	02	01	H3192_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											66.83	24	24	24				93.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3192	005	0	1	02	01	H3192_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											40.00	25	25	25				43.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3192	005	0	1	02	01	H3192_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											543.75	25						583.08	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	25			25			25			25			25		25
H3192	007	0	1	01	01	H3192_007_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3192	007	0	1	01	01	H3192_007_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3192	007	0	1	01	01	H3192_007_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				68.01	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	22	22	22				22	22	22				22		22
H3192	007	0	1	01	01	H3192_007_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.29	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3192	007	0	1	01	01	H3192_007_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				451.15	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											71.12	24	24	24				94.55	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.93	25	25	25				43.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											505.80	25						645.88	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	25			25			25			25			25		25
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											69.16	24	24	24				90.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.19	25	25	25				44.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											507.23	25						562.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3192	020	0	1	02	01	H3192_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																														
H3192	020	0	1	02	01	H3192_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																														
H3192	020	0	1	02	01	H3192_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											63.14	24	24	24				87.70	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3192	020	0	1	02	01	H3192_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											36.96	25	25	25				41.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3192	020	0	1	02	01	H3192_020_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											484.11	25						623.33	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	25			25			25			25			25		25
H3192	021	0	1	02	01	H3192_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																														
H3192	021	0	1	02	01	H3192_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																														
H3192	021	0	1	02	01	H3192_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											64.94	24	24	24				93.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3192	021	0	1	02	01	H3192_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											41.00	25	25	25				48.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3192	021	0	1	02	01	H3192_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											560.26	25						687.99	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	25			25			25			25			25		25
H3192	028	0	1	01	01	H3192_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3192	028	0	1	01	01	H3192_028_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3192	028	0	1	01	01	H3192_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				88.41	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3192	028	0	1	01	01	H3192_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				38.32	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3192	028	0	1	01	01	H3192_028_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				496.91	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3192	029	0	1	01	01	H3192_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3192	029	0	1	01	01	H3192_029_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3192	029	0	1	01	01	H3192_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				88.41	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3192	029	0	1	01	01	H3192_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				38.32	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3192	029	0	1	01	01	H3192_029_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				496.91	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3192	033	0	1	01	01	H3192_033_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	033	0	1	01	01	H3192_033_0	2			Generic	4	01	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																														
H3192	033	0	1	01	01	H3192_033_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.32	22	22	22				89.80	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3192	033	0	1	01	01	H3192_033_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.90	25	25	25				48.04	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3192	033	0	1	01	01	H3192_033_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											514.74	25						762.75	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	25			25			25			25			25		25
H3204	001	0	1	01	01	H3204_001_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		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	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																									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	5			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	25	25	25				25	25	25	25	25	25	25		25
H3204	001	0	1	01	01	H3204_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				2	2				30	60	90	30		31				60.00	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	25	25	25				25	25	25	25	25	25	25		25
H3204	001	0	1	01	01	H3204_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																														
H3204	007	0	1	01	01	H3204_007_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		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	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																									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	5			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	25	25	25				25	25	25	25	25	25	25		25
H3204	007	0	1	01	01	H3204_007_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				60.00	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	25	25	25				25	25	25	25	25	25	25		25
H3204	007	0	1	01	01	H3204_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3204	013	4	1	01	01	H3204_013_4	7		N	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																														
H3204	013	4	1	01	01	H3204_013_4	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				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	25	25	25				25	25	25				25		25
H3204	013	4	1	01	01	H3204_013_4	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				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	25	25	25				25	25	25				25		25
H3204	013	4	1	01	01	H3204_013_4	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																														
H3204	013	5	1	01	01	H3204_013_5	5		N	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																														
H3204	013	5	1	01	01	H3204_013_5	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				8.00	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	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				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	25	25	25				25	25	25				25		25
H3204	013	5	1	01	01	H3204_013_5	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				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	25	25	25				25	25	25				25		25
H3204	013	5	1	01	01	H3204_013_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																														
H3204	013	6	1	01	01	H3204_013_6	7		N	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																														
H3204	013	6	1	01	01	H3204_013_6	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				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	25	25	25				25	25	25				25		25
H3204	013	6	1	01	01	H3204_013_6	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				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	25	25	25				25	25	25				25		25
H3204	013	6	1	01	01	H3204_013_6	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																														
H3219	001	0	1	04	01	H3219_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																														
H3219	001	0	1	04	01	H3219_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																														
H3219	001	0	1	04	01	H3219_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											58.91	22	22	22				83.11	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3219	001	0	1	04	01	H3219_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											40.05	25	25	25				40.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	001	0	1	04	01	H3219_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.33	27						612.39	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	25			25			25			25			25		25
H3219	002	0	1	04	01	H3219_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																														
H3219	002	0	1	04	01	H3219_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					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.53	25	25	25				92.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	002	0	1	04	01	H3219_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											36.19	26	26	26				43.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	002	0	1	04	01	H3219_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											592.75	29						697.19	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3219	003	0	1	04	01	H3219_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																														
H3219	003	0	1	04	01	H3219_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					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	003	0	1	04	01	H3219_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											62.92	25	25	25				89.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	003	0	1	04	01	H3219_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											37.11	26	26	26				42.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	003	0	1	04	01	H3219_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											674.66	29						754.18	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3219	004	0	1	04	01	H3219_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																														
H3219	004	0	1	04	01	H3219_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																														
H3219	004	0	1	04	01	H3219_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											32.74	21	21	21				55.42	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H3219	004	0	1	04	01	H3219_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											31.40	33	33	33				31.96	33	33	33										33	33	33				33	33	33				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	004	0	1	04	01	H3219_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											696.34	33						802.89	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	25			25			25			25			25		25
H3219	008	0	1	04	01	H3219_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																														
H3219	008	0	1	04	01	H3219_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																														
H3219	008	0	1	04	01	H3219_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											61.47	24	24	24				87.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3219	008	0	1	04	01	H3219_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				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	008	0	1	04	01	H3219_008_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											486.53	25						573.20	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	25			25			25			25			25		25
H3219	012	0	1	04	01	H3219_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																														
H3219	012	0	1	04	01	H3219_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																														
H3219	012	0	1	04	01	H3219_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											60.94	24	24	24				88.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3219	012	0	1	04	01	H3219_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											40.08	25	25	25				45.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	012	0	1	04	01	H3219_012_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											546.67	25						747.30	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	25			25			25			25			25		25
H3219	014	0	1	04	01	H3219_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																														
H3219	014	0	1	04	01	H3219_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																														
H3219	014	0	1	04	01	H3219_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											67.65	24	24	24				94.23	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3219	014	0	1	04	01	H3219_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											41.46	25	25	25				48.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	014	0	1	04	01	H3219_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											565.11	25						729.05	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	25			25			25			25			25		25
H3219	015	0	1	04	01	H3219_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																														
H3219	015	0	1	04	01	H3219_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					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	015	0	1	04	01	H3219_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											63.56	22	22	22				83.76	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3219	015	0	1	04	01	H3219_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											36.46	25	25	25				45.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3219	015	0	1	04	01	H3219_015_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											487.53	25						716.19	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	25			25			25			25			25		25
H3219	016	0	1	04	01	H3219_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3219	016	0	1	04	01	H3219_016_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3219	016	0	1	04	01	H3219_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				82.05	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3219	016	0	1	04	01	H3219_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				39.75	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3219	016	0	1	04	01	H3219_016_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				508.11	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	001	0	1	01	01	H3239_001_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	001	0	1	01	01	H3239_001_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	001	0	1	01	01	H3239_001_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.92	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	22	22	22				22	22	22				22		22
H3239	001	0	1	01	01	H3239_001_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	001	0	1	01	01	H3239_001_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				498.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	002	0	1	01	01	H3239_002_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	002	0	1	01	01	H3239_002_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	002	0	1	01	01	H3239_002_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.51	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	22	22	22				22	22	22				22		22
H3239	002	0	1	01	01	H3239_002_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.52	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	25	25	25				25	25	25				25		25
H3239	002	0	1	01	01	H3239_002_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				468.04	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	005	0	1	01	01	H3239_005_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	005	0	1	01	01	H3239_005_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	005	0	1	01	01	H3239_005_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				67.54	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	22	22	22				22	22	22				22		22
H3239	005	0	1	01	01	H3239_005_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.73	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	005	0	1	01	01	H3239_005_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				487.39	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	007	0	1	01	01	H3239_007_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	007	0	1	01	01	H3239_007_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	007	0	1	01	01	H3239_007_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.41	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	22	22	22				22	22	22				22		22
H3239	007	0	1	01	01	H3239_007_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				37.58	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	007	0	1	01	01	H3239_007_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				479.03	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	010	0	1	01	01	H3239_010_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	010	0	1	01	01	H3239_010_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	010	0	1	01	01	H3239_010_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.94	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	22	22	22				22	22	22				22		22
H3239	010	0	1	01	01	H3239_010_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.37	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	25	25	25				25	25	25				25		25
H3239	010	0	1	01	01	H3239_010_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				474.56	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	012	0	1	01	01	H3239_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	012	0	1	01	01	H3239_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	012	0	1	01	01	H3239_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.06	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	22	22	22				22	22	22				22		22
H3239	012	0	1	01	01	H3239_012_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.97	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	012	0	1	01	01	H3239_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				462.06	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											66.11	24	24	24				86.52	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											35.05	25	25	25				40.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											519.76	25						502.37	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	25			25			25			25			25		25
H3239	015	0	1	01	01	H3239_015_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	015	0	1	01	01	H3239_015_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	015	0	1	01	01	H3239_015_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				66.07	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	22	22	22				22	22	22				22		22
H3239	015	0	1	01	01	H3239_015_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.42	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	015	0	1	01	01	H3239_015_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				428.84	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											65.55	24	24	24				86.02	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											481.33	25						648.85	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	25			25			25			25			25		25
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											71.60	24	24	24				93.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.03	25	25	25				39.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.80	25						654.40	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	25			25			25			25			25		25
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											63.86	24	24	24				88.42	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.45	25	25	25				46.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											531.60	25						647.43	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	25			25			25			25			25		25
H3239	023	0	1	01	01	H3239_023_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	023	0	1	01	01	H3239_023_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	023	0	1	01	01	H3239_023_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				68.11	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	22	22	22				22	22	22				22		22
H3239	023	0	1	01	01	H3239_023_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.50	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	023	0	1	01	01	H3239_023_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				473.49	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	026	0	1	01	01	H3239_026_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	026	0	1	01	01	H3239_026_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	026	0	1	01	01	H3239_026_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.41	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	22	22	22				22	22	22				22		22
H3239	026	0	1	01	01	H3239_026_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.80	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	026	0	1	01	01	H3239_026_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				476.98	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	027	0	1	01	01	H3239_027_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	027	0	1	01	01	H3239_027_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	027	0	1	01	01	H3239_027_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.72	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	22	22	22				22	22	22				22		22
H3239	027	0	1	01	01	H3239_027_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.53	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	027	0	1	01	01	H3239_027_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				473.88	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	028	0	1	01	01	H3239_028_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	028	0	1	01	01	H3239_028_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3239	028	0	1	01	01	H3239_028_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				67.16	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	22	22	22				22	22	22				22		22
H3239	028	0	1	01	01	H3239_028_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.47	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3239	028	0	1	01	01	H3239_028_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				453.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3239	030	0	1	01	01	H3239_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																														
H3239	030	0	1	01	01	H3239_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					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																														
H3239	030	0	1	01	01	H3239_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											66.35	22	22	22				84.55	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3239	030	0	1	01	01	H3239_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											37.99	25	25	25				45.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3239	030	0	1	01	01	H3239_030_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											494.03	25						737.66	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	25			25			25			25			25		25
H3240	013	0	1	01	01	H3240_013_0	5		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																														
H3240	013	0	1	01	01	H3240_013_0	5		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, Select Care Drugs																														
H3240	013	0	1	01	01	H3240_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		34				91.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3240	013	0	1	01	01	H3240_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		34				34.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3240	013	0	1	01	01	H3240_013_0	5		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																														
H3240	013	0	1	01	01	H3240_013_0	5		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																														
H3240	017	0	1	02	01	H3240_017_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																														
H3240	017	0	1	02	01	H3240_017_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.00	25	25	25				94.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H3240	017	0	1	02	01	H3240_017_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											39.00	25	25	25				24.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H3240	017	0	1	02	01	H3240_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3240	017	0	1	02	01	H3240_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3240	024	0	1	02	01	H3240_024_0	5		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																														
H3240	024	0	1	02	01	H3240_024_0	5		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, Select Care Drugs																														
H3240	024	0	1	02	01	H3240_024_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				82.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3240	024	0	1	02	01	H3240_024_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		34				35.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3240	024	0	1	02	01	H3240_024_0	5		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																														
H3240	024	0	1	02	01	H3240_024_0	5		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																														
H3251	002	0	1	01	01	H3251_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3251	002	0	1	01	01	H3251_002_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	12.00				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	6.00	12.00	18.00	0.00	0.00	0.00	6.00	12.00	12.00	0.00	0.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3251	002	0	1	01	01	H3251_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											51.59	20	20	20				41.41	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	16	16	16	20	20	20	16	16	16	20		20
H3251	002	0	1	01	01	H3251_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											66.03	42	42	42				67.88	38	38	38										42	42	42				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3251	002	0	1	01	01	H3251_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											591.24	27						648.61	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3256	004	1	1	04	01	H3256_004_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	004	1	1	04	01	H3256_004_1	4		N	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																														
H3256	004	1	1	04	01	H3256_004_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H3256	004	1	1	04	01	H3256_004_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	004	1	1	04	01	H3256_004_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				344.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	004	2	1	04	01	H3256_004_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	004	2	1	04	01	H3256_004_2	4		N	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																														
H3256	004	2	1	04	01	H3256_004_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H3256	004	2	1	04	01	H3256_004_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	004	2	1	04	01	H3256_004_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				344.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	005	1	1	04	01	H3256_005_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	005	1	1	04	01	H3256_005_1	4		N	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																														
H3256	005	1	1	04	01	H3256_005_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H3256	005	1	1	04	01	H3256_005_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	005	1	1	04	01	H3256_005_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				360.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	005	2	1	04	01	H3256_005_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	005	2	1	04	01	H3256_005_2	4		N	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																														
H3256	005	2	1	04	01	H3256_005_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H3256	005	2	1	04	01	H3256_005_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	005	2	1	04	01	H3256_005_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				360.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	006	1	1	04	01	H3256_006_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	006	1	1	04	01	H3256_006_1	4		N	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																														
H3256	006	1	1	04	01	H3256_006_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H3256	006	1	1	04	01	H3256_006_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	006	1	1	04	01	H3256_006_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	006	2	1	04	01	H3256_006_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3256	006	2	1	04	01	H3256_006_2	4		N	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																														
H3256	006	2	1	04	01	H3256_006_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H3256	006	2	1	04	01	H3256_006_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3256	006	2	1	04	01	H3256_006_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3259	001	0	1	01	01	H3259_001_0	11		N	Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31	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																														
H3259	001	0	1	01	01	H3259_001_0	11		N	Preferred Brand	4	10	1	1	2	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31				99.14	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	001	0	1	01	01	H3259_001_0	11		N	Non-Preferred Drug	4	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					14	31				6.86	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	001	0	1	01	01	H3259_001_0	11		N	Specialty Tier	4	11	1	1	4	1	010		10	010		1	30								30							14	31				460.64	25																				25																		25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3259	002	0	1	01	01	H3259_002_0	12		N	Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31	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																														
H3259	002	0	1	01	01	H3259_002_0	12		N	Preferred Brand	4	10	1	1	2	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31				80.01	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	002	0	1	01	01	H3259_002_0	12		N	Non-Preferred Drug	4	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					14	31				6.41	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	002	0	1	01	01	H3259_002_0	12		N	Specialty Tier	4	11	1	1	4	1	010		10	010		1	30								30							14	31				407.06	25																				25																		25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3259	003	0	1	01	01	H3259_003_0	11		N	Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31	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																														
H3259	003	0	1	01	01	H3259_003_0	11		N	Preferred Brand	4	10	1	1	2	1	111		10	111		1	30	60	100				1	2	30	60	100					14	31				97.72	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	003	0	1	01	01	H3259_003_0	11		N	Non-Preferred Drug	4	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					14	31				7.02	25	25	25																		25	25	25																25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3259	003	0	1	01	01	H3259_003_0	11		N	Specialty Tier	4	11	1	1	4	1	010		10	010		1	30								30							14	31				481.46	25																				25																		25		25								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3274	002	0	1	01	01	H3274_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 Drug, Specialty Tier																														
H3274	002	0	1	01	01	H3274_002_0	5			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 Drug, Specialty Tier																														
H3274	002	0	1	01	01	H3274_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3274	002	0	1	01	01	H3274_002_0	5			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3274	002	0	1	01	01	H3274_002_0	5			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3274	005	0	1	01	01	H3274_005_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 Drug, Specialty Tier																														
H3274	005	0	1	01	01	H3274_005_0	5			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 Drug, Specialty Tier																														
H3274	005	0	1	01	01	H3274_005_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3274	005	0	1	01	01	H3274_005_0	5			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3274	005	0	1	01	01	H3274_005_0	5			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3276	001	0	1	02	01	H3276_001_0	13		N	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																														
H3276	001	0	1	02	01	H3276_001_0	13		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				3.99	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3276	001	0	1	02	01	H3276_001_0	13		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				20.46	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	20	20	20				20	20	20				20		20
H3276	001	0	1	02	01	H3276_001_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.21	29	29	29																		29	29	29															29			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	25	25	25				25	25	25				25		25
H3276	001	0	1	02	01	H3276_001_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				697.30	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	25						25						25		25
H3276	001	0	1	02	01	H3276_001_0	13		N	Select Care Drugs	4	01	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																														
H3288	001	0	1	04	01	H3288_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																														
H3288	001	0	1	04	01	H3288_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																														
H3288	001	0	1	04	01	H3288_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											65.84	22	22	22				87.78	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	001	0	1	04	01	H3288_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											44.02	25	25	25				45.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	001	0	1	04	01	H3288_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											554.18	25						564.90	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	25			25			25			25			25		25
H3288	002	0	1	04	01	H3288_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																														
H3288	002	0	1	04	01	H3288_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																														
H3288	002	0	1	04	01	H3288_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											65.64	22	22	22				87.42	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	002	0	1	04	01	H3288_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											42.17	25	25	25				46.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	002	0	1	04	01	H3288_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											597.71	25						613.48	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	25			25			25			25			25		25
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											69.43	22	22	22				88.30	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											43.88	25	25	25				46.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											562.78	25						567.06	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											65.94	22	22	22				85.80	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											40.37	25	25	25				47.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											565.40	25						634.30	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	25			25			25			25			25		25
H3288	005	0	1	04	01	H3288_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																														
H3288	005	0	1	04	01	H3288_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																														
H3288	005	0	1	04	01	H3288_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											71.84	24	24	24				98.85	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	005	0	1	04	01	H3288_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											40.47	25	25	25				44.68	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	005	0	1	04	01	H3288_005_0	4			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											558.91	25						624.90	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	25			25			25			25			25		25
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											66.48	24	24	24				92.58	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.93	25	25	25				44.12	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											551.33	25						597.52	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	25			25			25			25			25		25
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											71.58	24	24	24				96.13	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.44	25	25	25				48.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											574.37	25						599.63	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	25			25			25			25			25		25
H3288	008	0	1	04	01	H3288_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																														
H3288	008	0	1	04	01	H3288_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																														
H3288	008	0	1	04	01	H3288_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											68.01	24	24	24				92.10	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	008	0	1	04	01	H3288_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											37.39	25	25	25				44.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	008	0	1	04	01	H3288_008_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											557.93	25						615.70	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	25			25			25			25			25		25
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											78.34	25	25	25				106.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											44.66	26	26	26				46.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											641.40	29						686.99	29												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	25			25			25			25			25		25
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											74.29	24	24	24				89.92	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.40	25	25	25				39.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											535.78	25						539.42	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	25			25			25			25			25		25
H3288	016	0	1	04	01	H3288_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																														
H3288	016	0	1	04	01	H3288_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																														
H3288	016	0	1	04	01	H3288_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											67.93	24	24	24				93.27	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	016	0	1	04	01	H3288_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											39.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	016	0	1	04	01	H3288_016_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											595.84	25						612.37	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	25			25			25			25			25		25
H3288	017	0	1	04	01	H3288_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																														
H3288	017	0	1	04	01	H3288_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																														
H3288	017	0	1	04	01	H3288_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											64.99	22	22	22				84.13	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	017	0	1	04	01	H3288_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											41.55	25	25	25				48.66	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	017	0	1	04	01	H3288_017_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											522.33	25						571.05	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	25			25			25			25			25		25
H3288	018	0	1	04	01	H3288_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																														
H3288	018	0	1	04	01	H3288_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	018	0	1	04	01	H3288_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											68.55	22	22	22				85.78	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	018	0	1	04	01	H3288_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											43.51	25	25	25				47.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	018	0	1	04	01	H3288_018_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											570.46	25						607.27	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	25			25			25			25			25		25
H3288	019	0	1	04	01	H3288_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																														
H3288	019	0	1	04	01	H3288_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																														
H3288	019	0	1	04	01	H3288_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											66.29	22	22	22				83.91	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	019	0	1	04	01	H3288_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											37.15	25	25	25				47.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	019	0	1	04	01	H3288_019_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											488.65	25						596.34	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	25			25			25			25			25		25
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											71.56	25	25	25				90.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											36.31	26	26	26				44.62	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											594.99	29						700.05	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											67.13	25	25	25				88.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											36.74	26	26	26				45.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											574.93	29						702.08	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3288	027	0	1	04	01	H3288_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																														
H3288	027	0	1	04	01	H3288_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																														
H3288	027	0	1	04	01	H3288_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											62.82	24	24	24				94.73	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	027	0	1	04	01	H3288_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											41.08	25	25	25				43.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	027	0	1	04	01	H3288_027_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											492.77	25						545.07	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	25			25			25			25			25		25
H3288	042	0	1	04	01	H3288_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																														
H3288	042	0	1	04	01	H3288_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																														
H3288	042	0	1	04	01	H3288_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											67.53	24	24	24				93.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	042	0	1	04	01	H3288_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											42.36	25	25	25				44.77	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	042	0	1	04	01	H3288_042_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											577.51	25						597.86	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	25			25			25			25			25		25
H3288	046	0	1	04	01	H3288_046_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	046	0	1	04	01	H3288_046_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	046	0	1	04	01	H3288_046_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.34	24	24	24				94.93	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	046	0	1	04	01	H3288_046_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											40.30	25	25	25				46.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	046	0	1	04	01	H3288_046_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											570.78	25						650.45	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3288	047	0	1	04	01	H3288_047_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	047	0	1	04	01	H3288_047_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	047	0	1	04	01	H3288_047_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.18	24	24	24				98.57	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3288	047	0	1	04	01	H3288_047_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											48.87	25	25	25				44.87	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	047	0	1	04	01	H3288_047_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											472.27	25						539.72	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	25			25			25			25			25		25
H3288	048	0	1	04	01	H3288_048_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	048	0	1	04	01	H3288_048_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	048	0	1	04	01	H3288_048_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.20	22	22	22				86.19	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3288	048	0	1	04	01	H3288_048_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	25	25	25				47.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3288	048	0	1	04	01	H3288_048_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											584.72	25						617.88	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	25			25			25			25			25		25
H3288	053	0	1	04	01	H3288_053_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3288	053	0	1	04	01	H3288_053_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3288	053	0	1	04	01	H3288_053_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				68.56	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	22	22	22				22	22	22				22		22
H3288	053	0	1	04	01	H3288_053_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				35.58	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3288	053	0	1	04	01	H3288_053_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				463.21	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3291	003	0	1	01	01	H3291_003_0	3			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 Drug, Specialty Tier																														
H3291	003	0	1	01	01	H3291_003_0	3			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 Drug, Specialty Tier																														
H3291	003	0	1	01	01	H3291_003_0	3			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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3291	003	0	1	01	01	H3291_003_0	3			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3291	003	0	1	01	01	H3291_003_0	3			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				769.26	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3305	015	0	1	02	01	H3305_015_0	17			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	0		0				0		0				0		0
H3305	015	0	1	02	01	H3305_015_0	17			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H3305	015	0	1	02	01	H3305_015_0	17			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				26.98	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H3305	015	0	1	02	01	H3305_015_0	17			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				67.64	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	25		25				25		25				25		25
H3305	015	0	1	02	01	H3305_015_0	17			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1385.09	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3305	022	0	1	02	01	H3305_022_0	16			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	0		0				0		0				0		0
H3305	022	0	1	02	01	H3305_022_0	16			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H3305	022	0	1	02	01	H3305_022_0	16			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				36.38	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H3305	022	0	1	02	01	H3305_022_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				88.37	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	25		25				25		25				25		25
H3305	022	0	1	02	01	H3305_022_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1008.34	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	Preferred Generic	4	01	1	1	1	1	110		01	110		1	30		100				1	2	30		100				30		31				1.34	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00		60.00				20.00		40.00				20.00		20.00	25		25				25		25				25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	Generic	4	01	1	1	2	1	110		01	110		1	30		90				2	2	30		90				30		31				4.99	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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				33.09	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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				101.33	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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				786.42	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	25						25						25		25
H3305	033	0	1	01	01	H3305_033_0	9		N	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H3305	034	0	1	01	01	H3305_034_0	9		N	Preferred Generic	4	01	1	1	1	1	110		01	110		1	30		100				1	2	30		100				30		31				1.46	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00		60.00				20.00		40.00				20.00		20.00	25		25				25		25				25		25
H3305	034	0	1	01	01	H3305_034_0	9		N	Generic	4	01	1	1	2	1	110		01	110		1	30		90				2	2	30		90				30		31				6.25	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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	034	0	1	01	01	H3305_034_0	9		N	Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	034	0	1	01	01	H3305_034_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				108.66	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		70.00				35.00		35.00	25		25				25		25				25		25
H3305	034	0	1	01	01	H3305_034_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				798.77	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	25						25						25		25
H3305	034	0	1	01	01	H3305_034_0	9		N	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H3312	002	0	1	01	01	H3312_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																														
H3312	002	0	1	01	01	H3312_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																														
H3312	002	0	1	01	01	H3312_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											93.18	24	24	24				109.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	002	0	1	01	01	H3312_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											53.59	25	25	25				55.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	002	0	1	01	01	H3312_002_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											484.67	25						638.34	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	25			25			25			25			25		25
H3312	018	0	1	02	01	H3312_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																														
H3312	018	0	1	02	01	H3312_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	02	01	H3312_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											70.57	24	24	24				102.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	018	0	1	02	01	H3312_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											40.40	25	25	25				47.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	018	0	1	02	01	H3312_018_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											586.55	25						686.48	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	25			25			25			25			25		25
H3312	048	0	1	01	01	H3312_048_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	048	0	1	01	01	H3312_048_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	048	0	1	01	01	H3312_048_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.56	24	24	24				98.13	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	048	0	1	01	01	H3312_048_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											40.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	048	0	1	01	01	H3312_048_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.13	25						611.54	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3312	062	0	1	01	01	H3312_062_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	062	0	1	01	01	H3312_062_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	062	0	1	01	01	H3312_062_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											81.76	24	24	24				102.32	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	062	0	1	01	01	H3312_062_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											40.04	25	25	25				47.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	062	0	1	01	01	H3312_062_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											536.89	25						649.13	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	25			25			25			25			25		25
H3312	064	0	1	01	01	H3312_064_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	064	0	1	01	01	H3312_064_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	064	0	1	01	01	H3312_064_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.50	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	064	0	1	01	01	H3312_064_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											46.45	25	25	25				47.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	064	0	1	01	01	H3312_064_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											587.92	25						696.61	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	25			25			25			25			25		25
H3312	065	0	1	02	01	H3312_065_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	065	0	1	02	01	H3312_065_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	065	0	1	02	01	H3312_065_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.93	22	22	22				97.27	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3312	065	0	1	02	01	H3312_065_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											44.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	065	0	1	02	01	H3312_065_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											621.33	27						730.20	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3312	069	0	1	01	01	H3312_069_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	069	0	1	01	01	H3312_069_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	069	0	1	01	01	H3312_069_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				82.91	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	22	22	22				22	22	22				22		22
H3312	069	0	1	01	01	H3312_069_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				48.48	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3312	069	0	1	01	01	H3312_069_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				494.14	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3312	070	0	1	01	01	H3312_070_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	070	0	1	01	01	H3312_070_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	070	0	1	01	01	H3312_070_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				75.07	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	22	22	22				22	22	22				22		22
H3312	070	0	1	01	01	H3312_070_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				38.51	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3312	070	0	1	01	01	H3312_070_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				482.96	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											83.28	24	24	24				105.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.15	25	25	25				51.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											547.12	25						722.48	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	25			25			25			25			25		25
H3312	081	0	1	01	01	H3312_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																														
H3312	081	0	1	01	01	H3312_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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.88	24	24	24				104.11	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	081	0	1	01	01	H3312_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											46.17	25	25	25				51.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	081	0	1	01	01	H3312_081_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											619.97	25						806.78	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	25			25			25			25			25		25
H3312	082	0	1	01	01	H3312_082_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	082	0	1	01	01	H3312_082_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	082	0	1	01	01	H3312_082_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.70	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	082	0	1	01	01	H3312_082_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											50.93	25	25	25				56.77	25	25	25										25	25	25				25	25	25				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	082	0	1	01	01	H3312_082_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											582.17	25						740.79	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	25			25			25			25			25		25
H3312	087	0	1	01	01	H3312_087_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	087	0	1	01	01	H3312_087_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	087	0	1	01	01	H3312_087_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				74.45	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	22	22	22				22	22	22				22		22
H3312	087	0	1	01	01	H3312_087_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				38.19	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		35.00	25	25	25				25	25	25				25		25
H3312	087	0	1	01	01	H3312_087_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				489.35	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3312	089	0	1	01	01	H3312_089_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	089	0	1	01	01	H3312_089_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	089	0	1	01	01	H3312_089_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				79.51	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	22	22	22				22	22	22				22		22
H3312	089	0	1	01	01	H3312_089_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				40.40	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		35.00	25	25	25				25	25	25				25		25
H3312	089	0	1	01	01	H3312_089_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				514.44	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3312	090	0	1	01	01	H3312_090_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	090	0	1	01	01	H3312_090_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3312	090	0	1	01	01	H3312_090_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				86.07	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	22	22	22				22	22	22				22		22
H3312	090	0	1	01	01	H3312_090_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				47.57	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	25	25	25				25	25	25				25		25
H3312	090	0	1	01	01	H3312_090_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				486.95	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3312	091	0	1	01	01	H3312_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																														
H3312	091	0	1	01	01	H3312_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					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	091	0	1	01	01	H3312_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											77.37	22	22	22				103.24	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3312	091	0	1	01	01	H3312_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											42.03	25	25	25				52.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	091	0	1	01	01	H3312_091_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											587.47	25						864.79	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	25			25			25			25			25		25
H3312	097	0	1	01	01	H3312_097_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	097	0	1	01	01	H3312_097_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	097	0	1	01	01	H3312_097_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.71	24	24	24				106.13	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3312	097	0	1	01	01	H3312_097_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											44.32	25	25	25				52.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3312	097	0	1	01	01	H3312_097_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											621.39	25						767.79	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	25			25			25			25			25		25
H3330	021	2	1	01	01	H3330_021_2	6			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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	6			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00		0.33				0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	2	1	01	01	H3330_021_2	6			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				44.53	25	25	25																								25	25	25				22	22	22			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25				25	25	25	22	22	22	25		25
H3330	021	2	1	01	01	H3330_021_2	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				66.76	28	28	28																								28	28	28				25	25	25			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	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H3330	021	2	1	01	01	H3330_021_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				975.83	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	2	1	01	01	H3330_021_2	6			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																														
H3330	021	3	1	01	01	H3330_021_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		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	6			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00		0.33				0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	3	1	01	01	H3330_021_3	6			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				44.53	25	25	25																								25	25	25				22	22	22			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25				25	25	25	22	22	22	25		25
H3330	021	3	1	01	01	H3330_021_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				66.76	28	28	28																								28	28	28				25	25	25			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	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H3330	021	3	1	01	01	H3330_021_3	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				975.83	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	3	1	01	01	H3330_021_3	6			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																														
H3330	021	5	1	01	01	H3330_021_5	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		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	6			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00		0.33				0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	5	1	01	01	H3330_021_5	6			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				44.53	25	25	25																								25	25	25				22	22	22			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25				25	25	25	22	22	22	25		25
H3330	021	5	1	01	01	H3330_021_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				66.76	28	28	28																								28	28	28				25	25	25			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	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H3330	021	5	1	01	01	H3330_021_5	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				975.83	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	021	5	1	01	01	H3330_021_5	6			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																														
H3330	038	0	1	01	01	H3330_038_0	5			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				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	5			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00		0.33				0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	038	0	1	01	01	H3330_038_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				38.16	25	25	25																								25	25	25				22	22	22			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25				25	25	25	22	22	22	25		25
H3330	038	0	1	01	01	H3330_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				59.33	28	28	28																								28	28	28				25	25	25			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	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H3330	038	0	1	01	01	H3330_038_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				768.17	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	038	0	1	01	01	H3330_038_0	5			Select Care Drugs	4	11	1	2	6	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	048	0	1	02	01	H3330_048_0	7			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	048	0	1	02	01	H3330_048_0	7			Generic	4	11	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	10.00	20.00	30.00																									10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00		0.33				0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	048	0	1	02	01	H3330_048_0	7			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				47.78	25	25	25																								25	25	25				22	22	22			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25				25	25	25	22	22	22	25		25
H3330	048	0	1	02	01	H3330_048_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				70.05	28	28	28																								28	28	28				25	25	25			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	70.00	105.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H3330	048	0	1	02	01	H3330_048_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1012.72	29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3330	048	0	1	02	01	H3330_048_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		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	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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	015	0	1	04	01	H3335_015_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	015	0	1	04	01	H3335_015_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.00	20	20	20				35.00	20	20	20										20	20	20				20	20	20			20			20								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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3335	015	0	1	04	01	H3335_015_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											62.00	50	50	50				42.00	36	36	36										50	50	50				36	36	36			50			36								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	015	0	1	04	01	H3335_015_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	018	0	1	04	01	H3335_018_0	8			Preferred Generic	3	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	12.00											9.00	18.00	27.00				4.00	8.00	12.00				9.00				4.00			0.30	0.13		0.30	0.13	0.13	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		4.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	018	0	1	04	01	H3335_018_0	8			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					7.00	14.00	21.00											11.00	22.00	33.00				7.00	14.00	21.00				11.00				7.00			0.37	0.23		0.37	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	7.00	14.00	21.00	11.00	22.00	33.00	7.00	14.00	21.00	11.00		7.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	018	0	1	04	01	H3335_018_0	8			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											48.00	25	25	25				41.00	21	21	21										25	25	25				21	21	21			25			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	25	25	25	21	21	21	25	25	25	21	21	21	25		21
H3335	018	0	1	04	01	H3335_018_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.00	25	25	25				30.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	018	0	1	04	01	H3335_018_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	038	0	1	04	01	H3335_038_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	038	0	1	04	01	H3335_038_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	038	0	1	04	01	H3335_038_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.00	20	20	20				38.00	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	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3335	038	0	1	04	01	H3335_038_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											67.00	50	50	50				45.00	37	37	37										50	50	50				37	37	37			50			37								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	038	0	1	04	01	H3335_038_0	8			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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	053	0	1	04	01	H3335_053_0	8			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				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	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	053	0	1	04	01	H3335_053_0	8			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	053	0	1	04	01	H3335_053_0	8			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											49.00	25	25	25				40.00	20	20	20										25	25	25				20	20	20			25			20								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		30.00	25	25	25	20	20	20	25	25	25	20	20	20	25		20
H3335	053	0	1	04	01	H3335_053_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.00	50	50	50				32.00	25	25	25										50	50	50				25	25	25			50			25								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	053	0	1	04	01	H3335_053_0	8			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	055	0	1	04	01	H3335_055_0	8			Preferred Generic	3	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	055	0	1	04	01	H3335_055_0	8			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	055	0	1	04	01	H3335_055_0	8			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.00	25	25	25				43.00	21	21	21										25	25	25				21	21	21			25			21								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		30.00	25	25	25	21	21	21	25	25	25	21	21	21	25		21
H3335	055	0	1	04	01	H3335_055_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.00	50	50	50				34.00	25	25	25										50	50	50				25	25	25			50			25								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	055	0	1	04	01	H3335_055_0	8			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	060	0	1	04	01	H3335_060_0	8			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				3.00			0.27	0.10		0.27	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	9.00	8.00		3.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	060	0	1	04	01	H3335_060_0	8			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	060	0	1	04	01	H3335_060_0	8			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.00	25	25	25				41.00	22	22	22										25	25	25				22	22	22			25			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	25	25	25	22	22	22	25	25	25	22	22	22	25		22
H3335	060	0	1	04	01	H3335_060_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											66.00	50	50	50				32.00	25	25	25										50	50	50				25	25	25			50			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	060	0	1	04	01	H3335_060_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	061	0	1	04	01	H3335_061_0	7			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				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	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	061	0	1	04	01	H3335_061_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	061	0	1	04	01	H3335_061_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.00	25	25	25				39.00	20	20	20										25	25	25				20	20	20			25			20								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		30.00	25	25	25	20	20	20	25	25	25	20	20	20	25		20
H3335	061	0	1	04	01	H3335_061_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											72.00	50	50	50				30.00	25	25	25										50	50	50				25	25	25			50			25								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	061	0	1	04	01	H3335_061_0	7			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	062	0	1	04	01	H3335_062_0	7			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	24.00					3.00	6.00	9.00											8.00	16.00	24.00				3.00	6.00	9.00				8.00				3.00			0.27	0.10		0.27	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	24.00	3.00	6.00	9.00	8.00	16.00	24.00	3.00	6.00	9.00	8.00		3.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	062	0	1	04	01	H3335_062_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	062	0	1	04	01	H3335_062_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.00	25	25	25				41.00	22	22	22										25	25	25				22	22	22			25			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	22	22	22	25	25	25	22	22	22	25		22
H3335	062	0	1	04	01	H3335_062_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											62.00	50	50	50				34.00	25	25	25										50	50	50				25	25	25			50			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3335	062	0	1	04	01	H3335_062_0	7			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	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3347	009	0	1	02	01	H3347_009_0	9			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	25	25	25						25				25		25
H3347	009	0	1	02	01	H3347_009_0	9			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	25	25	25						25				25		25
H3347	009	0	1	02	01	H3347_009_0	9			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					94.00																47.00				47.00		1.57						1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00						70.00				35.00		35.00	25	25	25						25				25		25
H3347	009	0	1	02	01	H3347_009_0	9			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	25	25	25						25				25		25
H3347	009	0	1	02	01	H3347_009_0	9			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				1147.38	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	25	25	25						25				25		25
H3347	016	0	1	02	01	H3347_016_0	8			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	25	25	25						25				25		25
H3347	016	0	1	02	01	H3347_016_0	8			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	25	25	25						25				25		25
H3347	016	0	1	02	01	H3347_016_0	8			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	25	25	25						25				25		25
H3347	016	0	1	02	01	H3347_016_0	8			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	25	25	25						25				25		25
H3347	016	0	1	02	01	H3347_016_0	8			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				1111.18	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	25	25	25						25				25		25
H3347	018	0	1	02	01	H3347_018_0	8			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	25	25	25						25				25		25
H3347	018	0	1	02	01	H3347_018_0	8			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	25	25	25						25				25		25
H3347	018	0	1	02	01	H3347_018_0	8			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	25	25	25						25				25		25
H3347	018	0	1	02	01	H3347_018_0	8			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	25	25	25						25				25		25
H3347	018	0	1	02	01	H3347_018_0	8			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	90				2	2			90				30		31				415.00	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	25	25	25						25				25		25
H3351	002	0	1	02	01	H3351_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	002	0	1	02	01	H3351_002_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	20.00					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	002	0	1	02	01	H3351_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.00	20	20	20				34.00	20	20	20										20	20	20				20	20	20			20			20								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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3351	002	0	1	02	01	H3351_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											65.00	50	50	50				37.00	33	33	33										50	50	50				33	33	33			50			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	002	0	1	02	01	H3351_002_0	7			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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	006	0	1	02	01	H3351_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	006	0	1	02	01	H3351_006_0	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	006	0	1	02	01	H3351_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											30.00	20	20	20				30.00	20	20	20										20	20	20				20	20	20			20			20								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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3351	006	0	1	02	01	H3351_006_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											59.00	50	50	50				42.00	37	37	37										50	50	50				37	37	37			50			37								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	006	0	1	02	01	H3351_006_0	8			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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	012	0	1	02	01	H3351_012_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	012	0	1	02	01	H3351_012_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	20.00					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	012	0	1	02	01	H3351_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.00	20	20	20				36.00	20	20	20										20	20	20				20	20	20			20			20								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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3351	012	0	1	02	01	H3351_012_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											64.00	50	50	50				41.00	33	33	33										50	50	50				33	33	33			50			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	012	0	1	02	01	H3351_012_0	7			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	017	0	1	01	01	H3351_017_0	7			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				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	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	017	0	1	01	01	H3351_017_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	017	0	1	01	01	H3351_017_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.00	25	25	25				38.00	21	21	21										25	25	25				21	21	21			25			21								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		30.00	25	25	25	21	21	21	25	25	25	21	21	21	25		21
H3351	017	0	1	01	01	H3351_017_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											57.00	40	40	40				33.00	25	25	25										40	40	40				25	25	25			40			25								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	017	0	1	01	01	H3351_017_0	7			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	019	0	1	02	01	H3351_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								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	019	0	1	02	01	H3351_019_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	20.00					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	019	0	1	02	01	H3351_019_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											36.00	20	20	20				37.00	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	70.00	30.00	60.00	60.00	35.00	70.00	70.00	30.00	60.00	60.00	35.00		30.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3351	019	0	1	02	01	H3351_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											65.00	50	50	50				41.00	33	33	33										50	50	50				33	33	33			50			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	019	0	1	02	01	H3351_019_0	7			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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	020	0	1	01	01	H3351_020_0	6			Preferred Generic	3	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	020	0	1	01	01	H3351_020_0	6			Generic	3	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	020	0	1	01	01	H3351_020_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.00	25	25	25				39.00	20	20	20										25	25	25				20	20	20			25			20								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		30.00	25	25	25	20	20	20	25	25	25	20	20	20	25		20
H3351	020	0	1	01	01	H3351_020_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.00	40	40	40				35.00	30	30	30										40	40	40				30	30	30			40			30								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	020	0	1	01	01	H3351_020_0	6			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	022	0	1	01	01	H3351_022_0	7			Preferred Generic	3	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				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	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	022	0	1	01	01	H3351_022_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	022	0	1	01	01	H3351_022_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.00	25	25	25				36.00	21	21	21										25	25	25				21	21	21			25			21								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		30.00	25	25	25	21	21	21	25	25	25	21	21	21	25		21
H3351	022	0	1	01	01	H3351_022_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											80.00	50	50	50				30.00	25	25	25										50	50	50				25	25	25			50			25								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		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	022	0	1	01	01	H3351_022_0	7			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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		30.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	023	0	1	01	01	H3351_023_0	7			Preferred Generic	3	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	12.00											9.00	18.00	27.00				4.00	8.00	12.00				9.00				4.00			0.30	0.13		0.30	0.13	0.13	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		4.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	023	0	1	01	01	H3351_023_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					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				15.00			0.67	0.50		0.67	0.50	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		15.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	023	0	1	01	01	H3351_023_0	7			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											45.00	25	25	25				36.00	21	21	21										25	25	25				21	21	21			25			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	21	21	21	25	25	25	21	21	21	25		21
H3351	023	0	1	01	01	H3351_023_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											75.00	50	50	50				32.00	25	25	25										50	50	50				25	25	25			50			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3351	023	0	1	01	01	H3351_023_0	7			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	30.00	60.00	90.00	25.00	50.00	75.00	30.00	60.00	90.00	25.00	50.00	75.00	30.00		25.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3359	001	0	1	01	01	H3359_001_0	8			Preferred Generic	4	11	3	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	000				0		0
H3359	001	0	1	01	01	H3359_001_0	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	3.00	6.00	3.00																			3.00	6.00	3.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00	6.00	3.00				3.00	6.00	3.00				3.00		3.00	25	25	25				25	25	25				25		25
H3359	001	0	1	01	01	H3359_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				45.09	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	21	21	21				21	21	21				21		21
H3359	001	0	1	01	01	H3359_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				26.86	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3359	001	0	1	01	01	H3359_001_0	8			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	25						25						25		25
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	0	0	0				0	0	0				0		0
H3359	019	0	1	01	01	H3359_019_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	6.00	12.00	18.00																			6.00	12.00	18.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00				6.00	12.00	18.00				6.00		6.00	25	25	25				25	25	25				25		25
H3359	019	0	1	01	01	H3359_019_0	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				31.78	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		35.00	16	16	16				16	16	16				16		16
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				30.44	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H3359	021	0	1	01	01	H3359_021_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H3359	021	0	1	01	01	H3359_021_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				4.27	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	23	23	23				23	23	23				23		23
H3359	021	0	1	01	01	H3359_021_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				44.78	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	23	23	23				23	23	23				23		23
H3359	021	0	1	01	01	H3359_021_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				35.67	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	25	25	25				25	25	25				25		25
H3359	021	0	1	01	01	H3359_021_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	35.00						35.00						35.00		35.00	25						25						25		25
H3359	038	0	1	01	01	H3359_038_0	7		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H3359	038	0	1	01	01	H3359_038_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				4.55	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	22	22	22				22	22	22				22		22
H3359	038	0	1	01	01	H3359_038_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				46.10	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	22	22	22				22	22	22				22		22
H3359	038	0	1	01	01	H3359_038_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				40.95	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	25	25	25				25	25	25				25		25
H3359	038	0	1	01	01	H3359_038_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	35.00						35.00						35.00		35.00	25						25						25		25
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	2.00		5.00																					5.00																2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		5.00						5.00				2.00		2.00	25		25						25				25		25
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	10.00		25.00																					25.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		25.00						25.00				10.00		10.00	25		25						25				25		25
H3362	020	0	1	01	01	H3362_020_0	6			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	37.00		92.50																					92.50																37.00				37.00		1.23						1.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	25		25						25				25		25
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				43.16	40		40																				40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	25		25						25				25		25
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				330.75	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3362	040	0	1	01	01	H3362_040_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				1	2			100				30		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		00
H3362	040	0	1	01	01	H3362_040_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	10.00		25.00																					25.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		25.00						25.00				10.00		10.00	25		25						25				25		25
H3362	040	0	1	01	01	H3362_040_0	7			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		90				2	2			90				30		34	47.00		117.50																					117.50																47.00				47.00		1.57						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	25		25						25				25		25
H3362	040	0	1	01	01	H3362_040_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				67.63	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	25		25						25				25		25
H3362	040	0	1	01	01	H3362_040_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				536.12	32																																					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3362	042	0	1	01	01	H3362_042_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	0		0						0				0		0
H3362	042	0	1	01	01	H3362_042_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		34	7.00		17.50																					17.50																7.00				7.00		0.23						0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	7.00		17.50						17.50				7.00		7.00	25		25						25				25		25
H3362	042	0	1	01	01	H3362_042_0	7			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34				56.82	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	16		16						16				16		16
H3362	042	0	1	01	01	H3362_042_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				65.34	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	25		25						25				25		25
H3362	042	0	1	01	01	H3362_042_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				491.93	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3362	043	0	1	01	01	H3362_043_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	0		0						0				0		0
H3362	043	0	1	01	01	H3362_043_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	2			90				30		34	10.00		25.00																					25.00																10.00				10.00		0.33						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		25.00						25.00				10.00		10.00	25		25						25				25		25
H3362	043	0	1	01	01	H3362_043_0	7			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34				64.40	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	19		19						19				19		19
H3362	043	0	1	01	01	H3362_043_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				62.77	42		42																				42															42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	25		25						25				25		25
H3362	043	0	1	01	01	H3362_043_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				601.85	32																																					32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3362	044	0	1	01	01	H3362_044_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	0		0						0				0		0
H3362	044	0	1	01	01	H3362_044_0	7			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	2			90				30		34	7.00		17.50																					17.50																7.00				7.00		0.23						0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	7.00		17.50						17.50				7.00		7.00	25		25						25				25		25
H3362	044	0	1	01	01	H3362_044_0	7			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				2	2			90				30		34				50.48	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	16		16						16				16		16
H3362	044	0	1	01	01	H3362_044_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				2	2			90				30		34				68.56	39		39																				39															39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		87.50						87.50				35.00		35.00	25		25						25				25		25
H3362	044	0	1	01	01	H3362_044_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				458.81	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	001	0	1	02	01	H3379_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	001	0	1	02	01	H3379_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	001	0	1	02	01	H3379_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3379	001	0	1	02	01	H3379_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				90.00	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	25						25			25			25		25
H3379	001	0	1	02	01	H3379_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H3379	039	0	1	02	01	H3379_039_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	039	0	1	02	01	H3379_039_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	039	0	1	02	01	H3379_039_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3379	039	0	1	02	01	H3379_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	039	0	1	02	01	H3379_039_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H3379	040	0	1	02	01	H3379_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	040	0	1	02	01	H3379_040_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	040	0	1	02	01	H3379_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H3379	040	0	1	02	01	H3379_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	040	0	1	02	01	H3379_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H3379	043	0	1	02	01	H3379_043_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	043	0	1	02	01	H3379_043_0	4			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		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	043	0	1	02	01	H3379_043_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3379	043	0	1	02	01	H3379_043_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				96.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	043	0	1	02	01	H3379_043_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H3379	052	0	1	02	01	H3379_052_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	052	0	1	02	01	H3379_052_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	052	0	1	02	01	H3379_052_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H3379	052	0	1	02	01	H3379_052_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	052	0	1	02	01	H3379_052_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H3379	053	0	1	02	01	H3379_053_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	053	0	1	02	01	H3379_053_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	053	0	1	02	01	H3379_053_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				55.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H3379	053	0	1	02	01	H3379_053_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	053	0	1	02	01	H3379_053_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				479.00	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	25						25			25			25		25
H3379	054	0	1	02	01	H3379_054_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	054	0	1	02	01	H3379_054_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	054	0	1	02	01	H3379_054_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H3379	054	0	1	02	01	H3379_054_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	054	0	1	02	01	H3379_054_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	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	25						25			25			25		25
H3379	056	0	1	02	01	H3379_056_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	056	0	1	02	01	H3379_056_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	056	0	1	02	01	H3379_056_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				50.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H3379	056	0	1	02	01	H3379_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	056	0	1	02	01	H3379_056_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				469.00	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	25						25			25			25		25
H3379	059	0	1	02	01	H3379_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	059	0	1	02	01	H3379_059_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3379	059	0	1	02	01	H3379_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H3379	059	0	1	02	01	H3379_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3379	059	0	1	02	01	H3379_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
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													21.00						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					1.00		3.00													45.00						2.00				15.00				15.00			0.48	0.03				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	1	3	1		110	01		100	1				31		90	1	2						90	31		31											61.86	20		20				61.86	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	013	0	1	01	01	H3384_013_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											49.85	25		25				49.85	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	019	0	1	01	01	H3384_019_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																														
H3384	019	0	1	01	01	H3384_019_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	019	0	1	01	01	H3384_019_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											62.31	20		20				62.31	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	019	0	1	01	01	H3384_019_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											38.82	20		20				38.82	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	019	0	1	01	01	H3384_019_0	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																														
H3384	069	1	1	01	01	H3384_069_1	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																														
H3384	069	1	1	01	01	H3384_069_1	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	069	1	1	01	01	H3384_069_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											66.21	20		20				66.21	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	069	1	1	01	01	H3384_069_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.83	25		25				52.83	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	20		20	20		20			20			20	20		20
H3384	069	1	1	01	01	H3384_069_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																														
H3384	069	2	1	01	01	H3384_069_2	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																														
H3384	069	2	1	01	01	H3384_069_2	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	069	2	1	01	01	H3384_069_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											66.21	20		20				66.21	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	069	2	1	01	01	H3384_069_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.83	25		25				52.83	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	20		20	20		20			20			20	20		20
H3384	069	2	1	01	01	H3384_069_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																														
H3384	069	3	1	01	01	H3384_069_3	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																														
H3384	069	3	1	01	01	H3384_069_3	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	069	3	1	01	01	H3384_069_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											66.21	20		20				66.21	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	069	3	1	01	01	H3384_069_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.83	25		25				52.83	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	20		20	20		20			20			20	20		20
H3384	069	3	1	01	01	H3384_069_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																														
H3384	070	1	1	01	01	H3384_070_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																														
H3384	070	1	1	01	01	H3384_070_1	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	070	1	1	01	01	H3384_070_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											64.80	20		20				64.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	070	1	1	01	01	H3384_070_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.47	25		25				51.47	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	20		20	20		20			20			20	20		20
H3384	070	1	1	01	01	H3384_070_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																														
H3384	070	2	1	01	01	H3384_070_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																														
H3384	070	2	1	01	01	H3384_070_2	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	070	2	1	01	01	H3384_070_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											64.80	20		20				64.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	070	2	1	01	01	H3384_070_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.47	25		25				51.47	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	20		20	20		20			20			20	20		20
H3384	070	2	1	01	01	H3384_070_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																														
H3384	070	3	1	01	01	H3384_070_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																														
H3384	070	3	1	01	01	H3384_070_3	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	070	3	1	01	01	H3384_070_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											64.80	20		20				64.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	070	3	1	01	01	H3384_070_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											51.47	25		25				51.47	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	20		20	20		20			20			20	20		20
H3384	070	3	1	01	01	H3384_070_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																														
H3384	071	0	1	01	01	H3384_071_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																														
H3384	071	0	1	01	01	H3384_071_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								17.00		51.00					3.00		9.00													51.00						7.00				17.00				17.00			0.55	0.10				0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3384	071	0	1	01	01	H3384_071_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											66.20	20		20				66.20	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3384	071	0	1	01	01	H3384_071_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											52.85	25		25				52.85	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	20		20	20		20			20			20	20		20
H3384	071	0	1	01	01	H3384_071_0	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																														
H3387	013	0	1	02	01	H3387_013_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	013	0	1	02	01	H3387_013_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				7.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3387	013	0	1	02	01	H3387_013_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				60.00	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	25		25						25				25		25
H3387	013	0	1	02	01	H3387_013_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				56.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	013	0	1	02	01	H3387_013_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				433.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	014	1	1	02	01	H3387_014_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	014	1	1	02	01	H3387_014_1	4		N	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																														
H3387	014	1	1	02	01	H3387_014_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H3387	014	1	1	02	01	H3387_014_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	014	1	1	02	01	H3387_014_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	014	2	1	02	01	H3387_014_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	014	2	1	02	01	H3387_014_2	4		N	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																														
H3387	014	2	1	02	01	H3387_014_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H3387	014	2	1	02	01	H3387_014_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	014	2	1	02	01	H3387_014_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	015	1	1	02	01	H3387_015_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	015	1	1	02	01	H3387_015_1	4		N	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																														
H3387	015	1	1	02	01	H3387_015_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H3387	015	1	1	02	01	H3387_015_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				60.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	015	1	1	02	01	H3387_015_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				372.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	015	2	1	02	01	H3387_015_2	6		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	015	2	1	02	01	H3387_015_2	6		N	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																														
H3387	015	2	1	02	01	H3387_015_2	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H3387	015	2	1	02	01	H3387_015_2	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				60.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	015	2	1	02	01	H3387_015_2	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				372.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3387	017	0	1	02	01	H3387_017_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3387	017	0	1	02	01	H3387_017_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3387	017	0	1	02	01	H3387_017_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	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	25		25						25				25		25
H3387	017	0	1	02	01	H3387_017_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H3387	017	0	1	02	01	H3387_017_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3388	002	0	1	01	01	H3388_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								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				0.00			0.10	0.00		0.10	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	002	0	1	01	01	H3388_002_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					0.00	0.00	0.00											16.00	32.00	48.00				0.00	0.00	0.00				16.00				0.00			0.53	0.00		0.53	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	002	0	1	01	01	H3388_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								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				40.00			1.50	1.33		1.50	1.33	1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3388	002	0	1	01	01	H3388_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											48.11	40	40	40				48.11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3388	002	0	1	01	01	H3388_002_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1484.48	33						1484.48	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	014	0	1	01	01	H3388_014_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				0.00			0.20	0.00		0.20	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	014	0	1	01	01	H3388_014_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					7.00	14.00	21.00											20.00	40.00	60.00				7.00	14.00	14.00				20.00				20.00			0.67	0.23		0.67	0.23	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	014	0	1	01	01	H3388_014_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.19	20	20	20				50.19	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	70.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3388	014	0	1	01	01	H3388_014_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											51.88	29	29	29				51.88	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	70.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3388	014	0	1	01	01	H3388_014_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1260.19	27						1260.19	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	020	0	1	01	01	H3388_020_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				0.00			0.17	0.00		0.17	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	020	0	1	01	01	H3388_020_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								18.00	36.00	54.00					2.00	4.00	6.00											18.00	36.00	54.00				2.00	4.00	4.00				18.00				2.00			0.60	0.07		0.60	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3388	020	0	1	01	01	H3388_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											45.69	20	20	20				45.69	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	70.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3388	020	0	1	01	01	H3388_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											68.30	37	37	37				68.30	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	70.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3388	020	0	1	01	01	H3388_020_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1538.36	30						1538.36	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3404	003	1	1	04	01	H3404_003_1	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	1	1	04	01	H3404_003_1	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	1	1	04	01	H3404_003_1	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	1	1	04	01	H3404_003_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.26	31	31	31				70.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	1	1	04	01	H3404_003_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											745.78	31						711.83	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3404	003	1	1	04	01	H3404_003_1	9			Select Care Drugs	4	11	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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	2	1	04	01	H3404_003_2	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	2	1	04	01	H3404_003_2	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	2	1	04	01	H3404_003_2	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.26	31	31	31				70.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3404	003	2	1	04	01	H3404_003_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											745.78	31						711.83	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3404	003	2	1	04	01	H3404_003_2	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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																														
H3407	001	0	1	01	01	H3407_001_0	8		N	Preferred Generic	4	01	1	1	1	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				2.00	22	22	22																		22	22	22																22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	001	0	1	01	01	H3407_001_0	8		N	Generic	4	01	1	1	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				11.33	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	001	0	1	01	01	H3407_001_0	8		N	Preferred Brand	4	10	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				83.34	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	25	25	25				25	25	25				25		25
H3407	001	0	1	01	01	H3407_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				89.75	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	25	25	25				25	25	25				25		25
H3407	001	0	1	01	01	H3407_001_0	8		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				415.95	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	001	0	1	01	01	H3407_001_0	8		N	Supplemental Drugs	4	11	2	2	6	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	002	0	1	01	01	H3407_002_0	8			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	002	0	1	01	01	H3407_002_0	8			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	002	0	1	01	01	H3407_002_0	8			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	35.00	70.00	105.00																			35.00	70.00	105.00																	35.00			35.00		1.17			1.17			1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3407	002	0	1	01	01	H3407_002_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				99.44	30	30	30																		30	30	30																30		30								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	25	25	25				25	25	25				25		25
H3407	002	0	1	01	01	H3407_002_0	8			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				495.99	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	002	0	1	01	01	H3407_002_0	8			Supplemental Drugs	4	11	2	2	6	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	003	0	1	01	01	H3407_003_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	003	0	1	01	01	H3407_003_0	7			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	003	0	1	01	01	H3407_003_0	7			Preferred Brand	4	10	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				66.35	20	20	20																		20	20	20																20		20								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	20	20	20				20	20	20				20		20
H3407	003	0	1	01	01	H3407_003_0	7			Non-Preferred Drug	4	10	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				90.78	27	27	27																		27	27	27																27		27								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	25	25	25				25	25	25				25		25
H3407	003	0	1	01	01	H3407_003_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				452.76	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3407	003	0	1	01	01	H3407_003_0	7			Supplemental Drugs	4	11	2	2	6	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H3418	001	0	1	04	01	H3418_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	001	0	1	04	01	H3418_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	001	0	1	04	01	H3418_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H3418	001	0	1	04	01	H3418_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	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	25						25			25			25		25
H3418	001	0	1	04	01	H3418_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H3418	002	0	1	04	01	H3418_002_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	002	0	1	04	01	H3418_002_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	002	0	1	04	01	H3418_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3418	002	0	1	04	01	H3418_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				94.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3418	002	0	1	04	01	H3418_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				352.00	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	25						25			25			25		25
H3418	004	0	1	04	01	H3418_004_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	004	0	1	04	01	H3418_004_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	004	0	1	04	01	H3418_004_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H3418	004	0	1	04	01	H3418_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3418	004	0	1	04	01	H3418_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				399.00	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	25						25			25			25		25
H3418	008	0	1	04	01	H3418_008_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	008	0	1	04	01	H3418_008_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3418	008	0	1	04	01	H3418_008_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3418	008	0	1	04	01	H3418_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3418	008	0	1	04	01	H3418_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				393.00	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	25						25			25			25		25
H3419	003	0	1	02	01	H3419_003_0	7			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3419	003	0	1	02	01	H3419_003_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 Drug, Specialty Tier																														
H3419	003	0	1	02	01	H3419_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	003	0	1	02	01	H3419_003_0	7			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	003	0	1	02	01	H3419_003_0	7			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, 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 Drug, 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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	004	0	1	02	01	H3419_004_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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 Drug, Specialty Tier																														
H3419	006	0	1	01	01	H3419_006_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 Drug, Specialty Tier																														
H3419	006	0	1	01	01	H3419_006_0	4			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 Drug, Specialty Tier																														
H3419	006	0	1	01	01	H3419_006_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	006	0	1	01	01	H3419_006_0	4			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	006	0	1	01	01	H3419_006_0	4			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3419	007	0	1	01	01	H3419_007_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 Drug, Specialty Tier																														
H3419	007	0	1	01	01	H3419_007_0	4			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 Drug, Specialty Tier																														
H3419	007	0	1	01	01	H3419_007_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	007	0	1	01	01	H3419_007_0	4			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3419	007	0	1	01	01	H3419_007_0	4			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	28																				28																		28		28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3443	001	0	1	01	01	H3443_001_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3443	001	0	1	01	01	H3443_001_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	25	25	25				25	25	25				25		25
H3443	001	0	1	01	01	H3443_001_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	25	25	25				25	25	25				25		25
H3443	001	0	1	01	01	H3443_001_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.67	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		35.00	25	25	25				25	25	25				25		25
H3443	001	0	1	01	01	H3443_001_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				657.08	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	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																														
H3443	002	0	1	01	01	H3443_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	25	25	25				25	25	25				25		25
H3443	002	0	1	01	01	H3443_002_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	25	25	25				25	25	25				25		25
H3443	002	0	1	01	01	H3443_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	25	25	25				25	25	25				25		25
H3443	002	0	1	01	01	H3443_002_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.49	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		35.00	25	25	25				25	25	25				25		25
H3443	002	0	1	01	01	H3443_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				828.07	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	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																														
H3443	003	0	1	01	01	H3443_003_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3443	003	0	1	01	01	H3443_003_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	25	25	25				25	25	25				25		25
H3443	003	0	1	01	01	H3443_003_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	25	25	25				25	25	25				25		25
H3443	003	0	1	01	01	H3443_003_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				45.82	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		35.00	25	25	25				25	25	25				25		25
H3443	003	0	1	01	01	H3443_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				597.92	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	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																														
H3443	005	0	1	01	01	H3443_005_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3443	005	0	1	01	01	H3443_005_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	25	25	25				25	25	25				25		25
H3443	005	0	1	01	01	H3443_005_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	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	25	25	25				25	25	25				25		25
H3443	005	0	1	01	01	H3443_005_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				42.35	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		35.00	25	25	25				25	25	25				25		25
H3443	005	0	1	01	01	H3443_005_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				444.81	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	11			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																														
H3443	006	0	1	01	01	H3443_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3443	006	0	1	01	01	H3443_006_0	10			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.02	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		35.00	25	25	25				25	25	25				25		25
H3443	006	0	1	01	01	H3443_006_0	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.45	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	25	25	25				25	25	25				25		25
H3443	006	0	1	01	01	H3443_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				52.94	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		35.00	25	25	25				25	25	25				25		25
H3443	006	0	1	01	01	H3443_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				428.88	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3443	006	0	1	01	01	H3443_006_0	10			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3443	007	0	1	01	01	H3443_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	25	25	25				25	25	25				25		25
H3443	007	0	1	01	01	H3443_007_0	7			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.33	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		35.00	25	25	25				25	25	25				25		25
H3443	007	0	1	01	01	H3443_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				74.59	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	25	25	25				25	25	25				25		25
H3443	007	0	1	01	01	H3443_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				48.24	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		35.00	25	25	25				25	25	25				25		25
H3443	007	0	1	01	01	H3443_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				510.89	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3443	007	0	1	01	01	H3443_007_0	7			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																														
H3447	013	0	1	02	01	H3447_013_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	013	0	1	02	01	H3447_013_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	25	25	25				86.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	013	0	1	02	01	H3447_013_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											28.00	30	30	30				20.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	013	0	1	02	01	H3447_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	013	0	1	02	01	H3447_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	018	0	1	01	01	H3447_018_0	5		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																														
H3447	018	0	1	01	01	H3447_018_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	018	0	1	01	01	H3447_018_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	018	0	1	01	01	H3447_018_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	018	0	1	01	01	H3447_018_0	5		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																														
H3447	018	0	1	01	01	H3447_018_0	5		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																														
H3447	024	0	1	02	01	H3447_024_0	4			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	4			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	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	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				63.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	024	0	1	02	01	H3447_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	024	0	1	02	01	H3447_024_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	024	0	1	02	01	H3447_024_0	4			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	5			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	5			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	025	0	1	02	01	H3447_025_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				86.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	025	0	1	02	01	H3447_025_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											36.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	025	0	1	02	01	H3447_025_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	025	0	1	02	01	H3447_025_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																														
H3447	033	0	1	02	01	H3447_033_0	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											50.00	25	25	25				71.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H3447	033	0	1	02	01	H3447_033_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											31.00	25	25	25				20.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H3447	033	0	1	02	01	H3447_033_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	033	0	1	02	01	H3447_033_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																														
H3447	037	0	1	02	01	H3447_037_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																														
H3447	037	0	1	02	01	H3447_037_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	037	0	1	02	01	H3447_037_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.00	25	25	25				119.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	037	0	1	02	01	H3447_037_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											42.00	30	30	30				33.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	037	0	1	02	01	H3447_037_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	037	0	1	02	01	H3447_037_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	0	0	0	0	0	0	0	0	0				0		0
H3447	038	1	1	02	01	H3447_038_1	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																														
H3447	038	1	1	02	01	H3447_038_1	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	038	1	1	02	01	H3447_038_1	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.00	25	25	25				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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	038	1	1	02	01	H3447_038_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	038	1	1	02	01	H3447_038_1	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	038	1	1	02	01	H3447_038_1	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																														
H3447	038	2	1	02	01	H3447_038_2	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	038	2	1	02	01	H3447_038_2	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.00	25	25	25				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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	038	2	1	02	01	H3447_038_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	038	2	1	02	01	H3447_038_2	4			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	038	2	1	02	01	H3447_038_2	4			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	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	039	0	1	02	01	H3447_039_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.00	25	25	25				82.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	039	0	1	02	01	H3447_039_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											28.00	30	30	30				15.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	039	0	1	02	01	H3447_039_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	039	0	1	02	01	H3447_039_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																														
H3447	042	1	1	02	01	H3447_042_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	042	1	1	02	01	H3447_042_1	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	042	1	1	02	01	H3447_042_1	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.00	25	25	25				72.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	042	1	1	02	01	H3447_042_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											31.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	042	1	1	02	01	H3447_042_1	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																														
H3447	042	1	1	02	01	H3447_042_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	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								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	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											46.00	25	25	25				72.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
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											31.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
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												31							31						31																	31			31								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	4			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	4			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	042	3	1	02	01	H3447_042_3	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.00	25	25	25				72.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	042	3	1	02	01	H3447_042_3	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											31.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	042	3	1	02	01	H3447_042_3	4			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																														
H3447	042	3	1	02	01	H3447_042_3	4			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	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																														
H3447	042	4	1	02	01	H3447_042_4	5			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	042	4	1	02	01	H3447_042_4	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.00	25	25	25				72.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3447	042	4	1	02	01	H3447_042_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											31.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	042	4	1	02	01	H3447_042_4	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	042	4	1	02	01	H3447_042_4	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																														
H3447	049	0	1	02	01	H3447_049_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	049	0	1	02	01	H3447_049_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	049	0	1	02	01	H3447_049_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											15.00	25	25	25				10.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	049	0	1	02	01	H3447_049_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	050	0	1	02	01	H3447_050_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	050	0	1	02	01	H3447_050_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											76.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	050	0	1	02	01	H3447_050_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											14.00	25	25	25				10.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	050	0	1	02	01	H3447_050_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	051	0	1	02	01	H3447_051_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	051	0	1	02	01	H3447_051_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											83.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	051	0	1	02	01	H3447_051_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											18.00	30	30	30				12.00	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	25	25	25	25	25	25	25	25	25				25		25
H3447	051	0	1	02	01	H3447_051_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	052	0	1	02	01	H3447_052_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																														
H3447	052	0	1	02	01	H3447_052_0	5			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																														
H3447	052	0	1	02	01	H3447_052_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.00	25	25	25				101.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H3447	052	0	1	02	01	H3447_052_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											17.00	30	30	30				11.00	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	25	25	25	25	25	25	25	25	25				25		25
H3447	052	0	1	02	01	H3447_052_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3447	053	0	1	01	01	H3447_053_0	5		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																														
H3447	053	0	1	01	01	H3447_053_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	053	0	1	01	01	H3447_053_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	053	0	1	01	01	H3447_053_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3447	053	0	1	01	01	H3447_053_0	5		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																														
H3447	053	0	1	01	01	H3447_053_0	5		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																														
H3447	056	0	1	02	01	H3447_056_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																														
H3447	056	0	1	02	01	H3447_056_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3447	056	0	1	02	01	H3447_056_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											48.00	25	25	25				61.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H3447	056	0	1	02	01	H3447_056_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											25.00	30	30	30				14.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3447	056	0	1	02	01	H3447_056_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																														
H3447	056	0	1	02	01	H3447_056_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																														
H3449	023	1	1	02	01	H3449_023_1	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	1	1	02	01	H3449_023_1	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	1	1	02	01	H3449_023_1	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	1	1	02	01	H3449_023_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.10	25	25	25				55.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	1	1	02	01	H3449_023_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.06	25						623.33	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	023	1	1	02	01	H3449_023_1	9			Select Care Drugs	4	11	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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	2	1	02	01	H3449_023_2	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	2	1	02	01	H3449_023_2	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	2	1	02	01	H3449_023_2	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.10	25	25	25				55.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	2	1	02	01	H3449_023_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.06	25						623.33	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	023	2	1	02	01	H3449_023_2	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	4	1	02	01	H3449_023_4	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	4	1	02	01	H3449_023_4	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	4	1	02	01	H3449_023_4	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.10	25	25	25				55.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	4	1	02	01	H3449_023_4	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.06	25						623.33	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	023	4	1	02	01	H3449_023_4	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	5	1	02	01	H3449_023_5	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	5	1	02	01	H3449_023_5	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	5	1	02	01	H3449_023_5	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.10	25	25	25				55.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	023	5	1	02	01	H3449_023_5	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.06	25						623.33	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	023	5	1	02	01	H3449_023_5	9			Select Care Drugs	4	11	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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	1	1	02	01	H3449_024_1	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	1	1	02	01	H3449_024_1	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	1	1	02	01	H3449_024_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.73	31	31	31				70.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	1	1	02	01	H3449_024_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.85	31						686.35	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	024	1	1	02	01	H3449_024_1	9			Select Care Drugs	4	11	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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	2	1	02	01	H3449_024_2	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	2	1	02	01	H3449_024_2	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	2	1	02	01	H3449_024_2	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.73	31	31	31				70.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	2	1	02	01	H3449_024_2	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.85	31						686.35	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	024	2	1	02	01	H3449_024_2	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	3	1	02	01	H3449_024_3	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	3	1	02	01	H3449_024_3	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	3	1	02	01	H3449_024_3	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											72.73	31	31	31				70.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	024	3	1	02	01	H3449_024_3	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											747.85	31						686.35	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	024	3	1	02	01	H3449_024_3	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	8			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	026	0	1	01	01	H3449_026_0	8			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	026	0	1	01	01	H3449_026_0	8			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	026	0	1	01	01	H3449_026_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											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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	026	0	1	01	01	H3449_026_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	25						1.00	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	026	0	1	01	01	H3449_026_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	9			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	1	1	01	01	H3449_027_1	9			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	1	1	01	01	H3449_027_1	9			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	1	1	01	01	H3449_027_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.54	25	25	25				56.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	1	1	01	01	H3449_027_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.61	25						688.09	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	9			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								3.00	3.00	3.00					0.00	0.00	0.00											3.00	3.00	3.00				0.00	0.00	0.00				3.00				3.00			0.10	0.00		0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3449	027	2	1	01	01	H3449_027_2	10			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	2	1	01	01	H3449_027_2	10			Generic	4	11	3	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					4.00	8.00	12.00											20.00	40.00	60.00				0.00	0.00	0.00				20.00				20.00			0.67	0.13		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	4.00	8.00	12.00	20.00	40.00	60.00	0.00	0.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	2	1	01	01	H3449_027_2	10			Preferred Brand	4	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	2	1	01	01	H3449_027_2	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.54	25	25	25				56.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3449	027	2	1	01	01	H3449_027_2	10			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.61	25						688.09	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	10			Select Care Drugs	4	11	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	3			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 Drug, Specialty Tier																														
H3467	005	0	1	02	01	H3467_005_0	3			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 Drug, Specialty Tier																														
H3467	005	0	1	02	01	H3467_005_0	3			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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3467	005	0	1	02	01	H3467_005_0	3			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3467	005	0	1	02	01	H3467_005_0	3			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				741.62	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3499	002	0	1	02	01	H3499_002_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H3499	002	0	1	02	01	H3499_002_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H3499	002	0	1	02	01	H3499_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.37	25	25	25				130.37	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3499	002	0	1	02	01	H3499_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											66.61	37	37	37				64.81	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3499	002	0	1	02	01	H3499_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3499	002	0	1	02	01	H3499_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	02	01	H3499_008_0	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3499	008	0	1	02	01	H3499_008_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3499	008	0	1	02	01	H3499_008_0	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											81.47	20	20	20				81.47	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H3499	008	0	1	02	01	H3499_008_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											41.31	32	32	32				41.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3499	008	0	1	02	01	H3499_008_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3499	008	0	1	02	01	H3499_008_0	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	010	0	1	02	01	H3528_010_0	13			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	15.00	30.00	30.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	010	0	1	02	01	H3528_010_0	13			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				36.08	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	010	0	1	02	01	H3528_010_0	13			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.80	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	25	25	25				25	25	25				25		25
H3528	010	0	1	02	01	H3528_010_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				904.12	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	25						25						25		25
H3528	010	0	1	02	01	H3528_010_0	13			Select Care Drugs	4	01	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																														
H3528	011	1	1	02	01	H3528_011_1	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	011	1	1	02	01	H3528_011_1	13			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	011	1	1	02	01	H3528_011_1	13			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.40	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	011	1	1	02	01	H3528_011_1	13			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				61.19	27	27	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				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	011	1	1	02	01	H3528_011_1	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1017.31	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3528	011	1	1	02	01	H3528_011_1	13			Select Care Drugs	4	01	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																														
H3528	011	2	1	02	01	H3528_011_2	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	011	2	1	02	01	H3528_011_2	13			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	011	2	1	02	01	H3528_011_2	13			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.40	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	011	2	1	02	01	H3528_011_2	13			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				61.19	27	27	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				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	011	2	1	02	01	H3528_011_2	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1017.31	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H3528	011	2	1	02	01	H3528_011_2	13			Select Care Drugs	4	01	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																														
H3528	014	0	1	02	01	H3528_014_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	014	0	1	02	01	H3528_014_0	13			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	15.00	30.00	30.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	014	0	1	02	01	H3528_014_0	13			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				35.37	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		35.00	25	25	25				25	25	25				25		25
H3528	014	0	1	02	01	H3528_014_0	13			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				66.15	27	27	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				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	014	0	1	02	01	H3528_014_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				985.78	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	25						25						25		25
H3528	014	0	1	02	01	H3528_014_0	13			Select Care Drugs	4	01	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																														
H3528	015	0	1	02	01	H3528_015_0	13			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	015	0	1	02	01	H3528_015_0	13			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	10.00	20.00	20.00																			10.00	20.00	20.00																10.00				10.00		0.32			0.32			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	015	0	1	02	01	H3528_015_0	13			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				26.02	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		35.00	25	25	25				25	25	25				25		25
H3528	015	0	1	02	01	H3528_015_0	13			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.95	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	25	25	25				25	25	25				25		25
H3528	015	0	1	02	01	H3528_015_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1012.03	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	25						25						25		25
H3528	015	0	1	02	01	H3528_015_0	13			Select Care Drugs	4	01	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																														
H3528	016	0	1	02	01	H3528_016_0	14			Preferred Generic	4	11	1	2	1	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	1.00	2.00	2.00																			1.00	2.00	2.00																1.00				1.00		0.03			0.03			0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	016	0	1	02	01	H3528_016_0	14			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	15.00	30.00	30.00																			15.00	30.00	30.00																15.00				15.00		0.48			0.48			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3528	016	0	1	02	01	H3528_016_0	14			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.38	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	016	0	1	02	01	H3528_016_0	14			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				56.79	27	27	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				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3528	016	0	1	02	01	H3528_016_0	14			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1042.10	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	25						25						25		25
H3528	016	0	1	02	01	H3528_016_0	14			Select Care Drugs	4	01	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																														
H3533	002	0	1	01	01	H3533_002_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	0		0				25		25	0		0	0		0
H3533	002	0	1	01	01	H3533_002_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	0		0				25		25	0		0	0		0
H3533	002	0	1	01	01	H3533_002_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H3533	002	0	1	01	01	H3533_002_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H3533	002	0	1	01	01	H3533_002_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	25						25			25			25		25
H3533	027	0	1	01	01	H3533_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	0		0				25		25	0		0	0		0
H3533	027	0	1	01	01	H3533_027_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H3533	027	0	1	01	01	H3533_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	25		25				25		25	25		25	25		25
H3533	027	0	1	01	01	H3533_027_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	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	25		25				25		25	25		25	25		25
H3533	027	0	1	01	01	H3533_027_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	25						25			25			25		25
H3533	033	0	1	01	01	H3533_033_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	0		0				25		25	0		0	0		0
H3533	033	0	1	01	01	H3533_033_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H3533	033	0	1	01	01	H3533_033_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	25		25				25		25	25		25	25		25
H3533	033	0	1	01	01	H3533_033_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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	25		25				25		25	25		25	25		25
H3533	033	0	1	01	01	H3533_033_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	25						25			25			25		25
H3533	034	1	1	01	01	H3533_034_1	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	0		0				25		25	0		0	0		0
H3533	034	1	1	01	01	H3533_034_1	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	0		0				25		25	0		0	0		0
H3533	034	1	1	01	01	H3533_034_1	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H3533	034	1	1	01	01	H3533_034_1	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	25		25				25		25	25		25	25		25
H3533	034	1	1	01	01	H3533_034_1	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	25						25			25			25		25
H3533	034	2	1	01	01	H3533_034_2	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	0		0				25		25	0		0	0		0
H3533	034	2	1	01	01	H3533_034_2	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	0		0				25		25	0		0	0		0
H3533	034	2	1	01	01	H3533_034_2	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H3533	034	2	1	01	01	H3533_034_2	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	25		25				25		25	25		25	25		25
H3533	034	2	1	01	01	H3533_034_2	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	25						25			25			25		25
H3533	035	0	1	01	01	H3533_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	0		0				25		25	0		0	0		0
H3533	035	0	1	01	01	H3533_035_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	25		25				25		25	25		0	25		25
H3533	035	0	1	01	01	H3533_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	25		25				25		25	25		25	25		25
H3533	035	0	1	01	01	H3533_035_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	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3551	001	0	1	01	01	H3551_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3551	001	0	1	01	01	H3551_001_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H3551	001	0	1	01	01	H3551_001_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			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	25	25	25				25	25	25				25		25
H3551	001	0	1	01	01	H3551_001_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				73.49	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	25	25	25				25	25	25				25		25
H3551	001	0	1	01	01	H3551_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				689.61	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3551	002	0	1	01	01	H3551_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3551	002	0	1	01	01	H3551_002_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H3551	002	0	1	01	01	H3551_002_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			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	25	25	25				25	25	25				25		25
H3551	002	0	1	01	01	H3551_002_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				71.04	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	25	25	25				25	25	25				25		25
H3551	002	0	1	01	01	H3551_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				729.58	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3551	004	0	1	01	01	H3551_004_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3551	004	0	1	01	01	H3551_004_0	4			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	5.00	10.00	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																														
H3551	004	0	1	01	01	H3551_004_0	4			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	47.00	94.00	141.00																			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	25	25	25				25	25	25				25		25
H3551	004	0	1	01	01	H3551_004_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				70.53	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	25	25	25				25	25	25				25		25
H3551	004	0	1	01	01	H3551_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				652.12	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3561	007	0	1	01	01	H3561_007_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	007	0	1	01	01	H3561_007_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	007	0	1	01	01	H3561_007_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.26	20	20	20				82.26	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H3561	007	0	1	01	01	H3561_007_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											41.26	32	32	32				41.26	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3561	007	0	1	01	01	H3561_007_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	007	0	1	01	01	H3561_007_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	008	0	1	01	01	H3561_008_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	008	0	1	01	01	H3561_008_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	008	0	1	01	01	H3561_008_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.73	20	20	20				75.73	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H3561	008	0	1	01	01	H3561_008_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											44.48	32	32	32				44.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3561	008	0	1	01	01	H3561_008_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	008	0	1	01	01	H3561_008_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	009	0	1	01	01	H3561_009_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	009	0	1	01	01	H3561_009_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	009	0	1	01	01	H3561_009_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											94.94	25	25	25				94.94	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3561	009	0	1	01	01	H3561_009_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3561	009	0	1	01	01	H3561_009_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3561	009	0	1	01	01	H3561_009_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3597	001	0	1	02	01	H3597_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																														
H3597	001	0	1	02	01	H3597_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																														
H3597	001	0	1	02	01	H3597_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											67.97	22	22	22				88.36	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3597	001	0	1	02	01	H3597_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											42.07	25	25	25				46.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3597	001	0	1	02	01	H3597_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											587.74	27						591.53	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	25			25			25			25			25		25
H3597	011	0	1	02	01	H3597_011_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3597	011	0	1	02	01	H3597_011_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3597	011	0	1	02	01	H3597_011_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.40	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	22	22	22				22	22	22				22		22
H3597	011	0	1	02	01	H3597_011_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.21	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	25	25	25				25	25	25				25		25
H3597	011	0	1	02	01	H3597_011_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				472.67	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3597	012	0	1	02	01	H3597_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3597	012	0	1	02	01	H3597_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3597	012	0	1	02	01	H3597_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.29	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	22	22	22				22	22	22				22		22
H3597	012	0	1	02	01	H3597_012_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.54	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	25	25	25				25	25	25				25		25
H3597	012	0	1	02	01	H3597_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				470.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3597	017	0	1	02	01	H3597_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																														
H3597	017	0	1	02	01	H3597_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																														
H3597	017	0	1	02	01	H3597_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											72.16	24	24	24				96.85	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3597	017	0	1	02	01	H3597_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											41.52	25	25	25				47.41	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3597	017	0	1	02	01	H3597_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											543.09	25						606.52	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	25			25			25			25			25		25
H3597	018	0	1	02	01	H3597_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																														
H3597	018	0	1	02	01	H3597_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																														
H3597	018	0	1	02	01	H3597_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											71.50	24	24	24				96.65	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3597	018	0	1	02	01	H3597_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											41.21	25	25	25				47.70	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3597	018	0	1	02	01	H3597_018_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											540.36	25						605.10	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	25			25			25			25			25		25
H3653	004	0	1	02	01	H3653_004_0	12			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	25		25				25		25				25		25
H3653	004	0	1	02	01	H3653_004_0	12			Generic	4	11	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	25		25				25		25				25		25
H3653	004	0	1	02	01	H3653_004_0	12			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				20.97	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		35.00	21		21				21		21				21		21
H3653	004	0	1	02	01	H3653_004_0	12			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				67.96	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		35.00	25		25				25		25				25		25
H3653	004	0	1	02	01	H3653_004_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					32																				32																	32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3653	015	0	1	02	01	H3653_015_0	15			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	25		25				25		25				25		25
H3653	015	0	1	02	01	H3653_015_0	15			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	25		25				25		25				25		25
H3653	015	0	1	02	01	H3653_015_0	15			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				34.41	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	20		20				20		20				20		20
H3653	015	0	1	02	01	H3653_015_0	15			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				79.47	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		35.00	25		25				25		25				25		25
H3653	015	0	1	02	01	H3653_015_0	15			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				280.63	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3653	022	0	1	02	01	H3653_022_0	13			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	25		25				25		25				25		25
H3653	022	0	1	02	01	H3653_022_0	13			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	25		25				25		25				25		25
H3653	022	0	1	02	01	H3653_022_0	13			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				37.86	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		35.00	23		23				23		23				23		23
H3653	022	0	1	02	01	H3653_022_0	13			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				68.17	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		35.00	25		25				25		25				25		25
H3653	022	0	1	02	01	H3653_022_0	13			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				345.33	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3655	041	0	1	02	01	H3655_041_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																														
H3655	041	0	1	02	01	H3655_041_0	5			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	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	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3655	041	0	1	02	01	H3655_041_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				23.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3655	041	0	1	02	01	H3655_041_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3655	041	0	1	02	01	H3655_041_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																														
H3655	045	1	1	02	01	H3655_045_1	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																														
H3655	045	1	1	02	01	H3655_045_1	5			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																														
H3655	045	1	1	02	01	H3655_045_1	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				76.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3655	045	1	1	02	01	H3655_045_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.00	30	30	30				19.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3655	045	1	1	02	01	H3655_045_1	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3655	045	1	1	02	01	H3655_045_1	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																														
H3655	045	2	1	02	01	H3655_045_2	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																														
H3655	045	2	1	02	01	H3655_045_2	5			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																														
H3655	045	2	1	02	01	H3655_045_2	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				76.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3655	045	2	1	02	01	H3655_045_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.00	30	30	30				19.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3655	045	2	1	02	01	H3655_045_2	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3655	045	2	1	02	01	H3655_045_2	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																														
H3655	045	3	1	02	01	H3655_045_3	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																														
H3655	045	3	1	02	01	H3655_045_3	5			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																														
H3655	045	3	1	02	01	H3655_045_3	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				76.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3655	045	3	1	02	01	H3655_045_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.00	30	30	30				19.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3655	045	3	1	02	01	H3655_045_3	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3655	045	3	1	02	01	H3655_045_3	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																														
H3655	045	4	1	02	01	H3655_045_4	4			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	4			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																														
H3655	045	4	1	02	01	H3655_045_4	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				76.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H3655	045	4	1	02	01	H3655_045_4	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											30.00	30	30	30				19.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H3655	045	4	1	02	01	H3655_045_4	4			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																														
H3655	045	4	1	02	01	H3655_045_4	4			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	6			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	028	0	1	02	01	H3660_028_0	6			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	028	0	1	02	01	H3660_028_0	6			Preferred Brand	4	11	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		117.50					41.00		102.50							102.50																41.00				41.00			1.57	1.37				1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		102.50			102.50				35.00		35.00	25		25	25		25			25				25		25
H3660	028	0	1	02	01	H3660_028_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											63.09	50		50				59.41	39		39						39															39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		105.00			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	028	0	1	02	01	H3660_028_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											791.48	33						656.76	33						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	25			25			25						25		25
H3660	028	0	1	02	01	H3660_028_0	6			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	029	0	1	02	01	H3660_029_0	7			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		25
H3660	029	0	1	02	01	H3660_029_0	7			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	029	0	1	02	01	H3660_029_0	7			Preferred Brand	4	11	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		117.50					41.00		102.50							102.50																41.00				41.00			1.57	1.37				1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		102.50			102.50				35.00		35.00	25		25	25		25			25				25		25
H3660	029	0	1	02	01	H3660_029_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											80.35	50		50				66.12	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	029	0	1	02	01	H3660_029_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											774.34	32						754.98	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		35.00	25			25			25						25		25
H3660	029	0	1	02	01	H3660_029_0	7			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	044	0	1	01	01	H3660_044_0	7			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	044	0	1	01	01	H3660_044_0	7			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	044	0	1	01	01	H3660_044_0	7			Preferred Brand	4	11	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								47.00		117.50					41.00		102.50							102.50																41.00				41.00			1.57	1.37				1.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		102.50			102.50				35.00		35.00	25		25	25		25			25				25		25
H3660	044	0	1	01	01	H3660_044_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											86.15	50		50				65.92	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	044	0	1	01	01	H3660_044_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											649.21	31						756.81	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H3660	044	0	1	01	01	H3660_044_0	7			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							15.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			25				0		0
H3660	050	0	1	01	01	H3660_050_0	7			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	050	0	1	01	01	H3660_050_0	7			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				25		25
H3660	050	0	1	01	01	H3660_050_0	7			Preferred Brand	4	11	3	1	3	1		110	01	100		1				30		90	1	2			90				30		31											81.57	25		25				81.96	23		23						23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		105.00			105.00				35.00		35.00	25		25	23		23			23				23		23
H3660	050	0	1	01	01	H3660_050_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											66.40	50		50				73.07	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	050	0	1	01	01	H3660_050_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											411.54	29						820.41	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	25			25			25						25		25
H3660	050	0	1	01	01	H3660_050_0	7			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	1	1	01	01	H3660_053_1	6			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	1	1	01	01	H3660_053_1	6			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	1	1	01	01	H3660_053_1	6			Preferred Brand	4	11	3	1	3	1		110	01	100		1				30		90	1	2			90				30		31											79.69	25		25				77.81	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			105.00				35.00		35.00	25		25	21		21			21				21		21
H3660	053	1	1	01	01	H3660_053_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											85.90	50		50				84.54	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	053	1	1	01	01	H3660_053_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											884.11	30						801.97	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		35.00	25			25			25						25		25
H3660	053	1	1	01	01	H3660_053_1	6			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	2	1	01	01	H3660_053_2	5			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	2	1	01	01	H3660_053_2	5			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	053	2	1	01	01	H3660_053_2	5			Preferred Brand	4	11	3	1	3	1		110	01	100		1				30		90	1	2			90				30		31											79.69	25		25				77.81	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			105.00				35.00		35.00	25		25	21		21			21				21		21
H3660	053	2	1	01	01	H3660_053_2	5			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											85.90	50		50				84.54	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	053	2	1	01	01	H3660_053_2	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											884.11	30						801.97	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		35.00	25			25			25						25		25
H3660	053	2	1	01	01	H3660_053_2	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	057	0	1	01	01	H3660_057_0	6			Preferred Generic	4	01	1	2	1	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	057	0	1	01	01	H3660_057_0	6			Generic	4	11	1	2	2	1		110	01	100		1				30		90	1	2			90				30		31								10.00		25.00					0.00		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	10.00		25.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
H3660	057	0	1	01	01	H3660_057_0	6			Preferred Brand	4	11	3	1	3	1		110	01	100		1				30		90	1	2			90				30		31											82.13	25		25				82.53	23		23						23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00	35.00		105.00			105.00				35.00		35.00	25		25	23		23			23				23		23
H3660	057	0	1	01	01	H3660_057_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01	100		1				30		90	1	2			90				30		31											66.52	50		50				73.45	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			105.00				35.00		35.00	25		25	25		25			25				25		25
H3660	057	0	1	01	01	H3660_057_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											414.53	29						827.62	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	25			25			25						25		25
H3660	057	0	1	01	01	H3660_057_0	6			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		100	1	2			100				30		31								6.00		15.00					0.00		0.00							0.00																0.00				0.00			0.20	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	6.00		15.00	0.00		0.00			0.00				0.00		0.00	25		25	0		0			0				0		0
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								8.00	16.00	24.00					0.00	0.00	0.00					0.00	0.00	0.00																8.00				0.00			0.27	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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								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			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	53.17	20	20	20	47.00	94.00	141.00	53.17	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	20	20	20	20	20	20	20	20	20				20		20
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											89.13	50	50	50				89.13	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											724.96	33						724.96	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								16.00	32.00	48.00					6.00	12.00	18.00					6.00	12.00	16.00																16.00				6.00			0.53	0.20	0.20			0.19	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	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.51	20	20	20				49.51	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	20	20	20	20	20	20	20	20	20				20		20
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											74.88	40	40	40				74.88	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	25	25	25	25	25	25	25	25	25				25		25
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											766.91	30						766.91	30						30																	30			30								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								7.00	14.00	21.00					0.00	0.00	0.00					0.00	0.00	0.00																7.00				0.00			0.23	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								15.00	30.00	45.00					8.00	16.00	24.00					8.00	16.00	20.00																15.00				8.00			0.50	0.27	0.27			0.26	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	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											51.40	20	20	20				51.40	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	20	20	20	20	20	20	20	20	20				20		20
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											88.24	40	40	40				88.24	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	25	25	25	25	25	25	25	25	25				25		25
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											692.41	30						692.41	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3668	018	1	1	01	01	H3668_018_1	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H3668	018	1	1	01	01	H3668_018_1	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	25	25	25				0	0	0				25		25
H3668	018	1	1	01	01	H3668_018_1	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				30.27	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3668	018	1	1	01	01	H3668_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				84.48	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	25	25	25				25	25	25				25		25
H3668	018	1	1	01	01	H3668_018_1	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	35.00						35.00						35.00		35.00	25						25						25		25
H3668	018	2	1	01	01	H3668_018_2	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H3668	018	2	1	01	01	H3668_018_2	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	25	25	25				0	0	0				25		25
H3668	018	2	1	01	01	H3668_018_2	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				30.27	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3668	018	2	1	01	01	H3668_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				84.48	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	25	25	25				25	25	25				25		25
H3668	018	2	1	01	01	H3668_018_2	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	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				0	0	0				25		25
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				39.78	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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				88.86	45	45	45																		45	45	45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3668	019	2	1	01	01	H3668_019_2	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H3668	019	2	1	01	01	H3668_019_2	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00	10.00	15.00				0.00	0.00	0.00				5.00		5.00	25	25	25				0	0	0				25		25
H3668	019	2	1	01	01	H3668_019_2	8			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				39.78	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3668	019	2	1	01	01	H3668_019_2	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				88.86	45	45	45																		45	45	45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3668	019	2	1	01	01	H3668_019_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3668	020	0	1	01	01	H3668_020_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	0	0	0				0	0	0				0		0
H3668	020	0	1	01	01	H3668_020_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	25	25	25				0	0	0				25		25
H3668	020	0	1	01	01	H3668_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				42.10	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	25	25	25				25	25	25				25		25
H3668	020	0	1	01	01	H3668_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				86.50	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3668	020	0	1	01	01	H3668_020_0	7			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	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				0	0	0				25		25
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				36.96	25	25	25																		25	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	25	25	25				25	25	25				25		25
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				83.61	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	25	25	25				25	25	25				25		25
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					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	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	0	0	0				0	0	0				0		0
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	25	25	25				0	0	0				25		25
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				33.46	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	25	25	25				25	25	25				25		25
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				79.20	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3668	025	0	1	01	01	H3668_025_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	0	0	0				0	0	0				0		0
H3668	025	0	1	01	01	H3668_025_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	0	0	0				0	0	0				0		0
H3668	025	0	1	01	01	H3668_025_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				38.95	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3668	025	0	1	01	01	H3668_025_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				92.66	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3668	025	0	1	01	01	H3668_025_0	6			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	35.00						35.00						35.00		35.00	25						25						25		25
H3668	026	0	1	01	01	H3668_026_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	0	0	0				0	0	0				0		0
H3668	026	0	1	01	01	H3668_026_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	0	0	0				0	0	0				0		0
H3668	026	0	1	01	01	H3668_026_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				30.41	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	25	25	25				25	25	25				25		25
H3668	026	0	1	01	01	H3668_026_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				71.67	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	25	25	25				25	25	25				25		25
H3668	026	0	1	01	01	H3668_026_0	6			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	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	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	25	25	25				0	0	0				25		25
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				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	25	25	25				25	25	25				25		25
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				81.16	40	40	40																		40	40	40															40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3668	031	0	1	01	01	H3668_031_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	0	0	0				0	0	0				0		0
H3668	031	0	1	01	01	H3668_031_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	25	25	25				0	0	0				25		25
H3668	031	0	1	01	01	H3668_031_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				41.93	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3668	031	0	1	01	01	H3668_031_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				69.97	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	25	25	25				25	25	25				25		25
H3668	031	0	1	01	01	H3668_031_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	35.00						35.00						35.00		35.00	25						25						25		25
H3672	013	0	1	01	01	H3672_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								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	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					5.00	10.00	15.00											20.00	40.00	60.00				5.00	10.00	15.00				20.00				20.00			0.67	0.17		0.67	0.17	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3672	013	0	1	01	01	H3672_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											48.31	20	20	20				46.62	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3672	013	0	1	01	01	H3672_013_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.52	40	40	40				30.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3672	013	0	1	01	01	H3672_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																														
H3672	019	0	1	01	01	H3672_019_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																														
H3672	019	0	1	01	01	H3672_019_0	5		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				6.21	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3672	019	0	1	01	01	H3672_019_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				56.38	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3672	019	0	1	01	01	H3672_019_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				26.27	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3672	019	0	1	01	01	H3672_019_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																														
H3672	020	0	1	01	01	H3672_020_0	5			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	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					4.00	8.00	12.00											20.00	40.00	60.00				4.00	8.00	12.00				20.00				20.00			0.67	0.13		0.67	0.13	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3672	020	0	1	01	01	H3672_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											46.56	20	20	20				48.33	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3672	020	0	1	01	01	H3672_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											41.05	40	40	40				31.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3672	020	0	1	01	01	H3672_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																														
H3672	023	0	1	01	01	H3672_023_0	5			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	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					2.00	4.00	6.00											20.00	40.00	60.00				2.00	4.00	6.00				20.00				20.00			0.67	0.07		0.67	0.07	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3672	023	0	1	01	01	H3672_023_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.85	20	20	20				49.44	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3672	023	0	1	01	01	H3672_023_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											50.55	40	40	40				28.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3672	023	0	1	01	01	H3672_023_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3706	001	0	1	01	01	H3706_001_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					0.00		0.00											6.00		18.00				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																														
H3706	001	0	1	01	01	H3706_001_0	4			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				30		100	30		31								14.00		42.00					8.00		0.00											14.00		42.00				8.00		0.00				14.00				14.00			0.47	0.27		0.47	0.27	0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	14.00		42.00	8.00		0.00	14.00		42.00	8.00		0.00	14.00		14.00	25		25	25		0	25		25	25		0	25		25
H3706	001	0	1	01	01	H3706_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					41.00		82.00											47.00		141.00				41.00		82.00				47.00				47.00			1.57	1.37		1.57	1.37	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		82.00	35.00		105.00	35.00		82.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	001	0	1	01	01	H3706_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											75.28	50		50				73.80	40		40										50		50				40		40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	001	0	1	01	01	H3706_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											794.20	33						621.25	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3706	023	0	1	01	01	H3706_023_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					0.00		0.00											6.00		18.00				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																														
H3706	023	0	1	01	01	H3706_023_0	4			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				30		100	30		31								16.00		48.00					10.00		0.00											16.00		48.00				10.00		0.00				16.00				16.00			0.53	0.33		0.53	0.33	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	16.00		48.00	10.00		0.00	16.00		48.00	10.00		0.00	16.00		16.00	25		25	25		0	25		25	25		0	25		25
H3706	023	0	1	01	01	H3706_023_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					41.00		82.00											47.00		141.00				41.00		82.00				47.00				47.00			1.57	1.37		1.57	1.37	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		82.00	35.00		105.00	35.00		82.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	023	0	1	01	01	H3706_023_0	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											79.88	50		50				72.95	40		40										50		50				40		40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	023	0	1	01	01	H3706_023_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											633.54	33						610.57	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3706	024	0	1	01	01	H3706_024_0	6			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								6.00		18.00					0.00		0.00											6.00		18.00				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																														
H3706	024	0	1	01	01	H3706_024_0	6			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				30		100	30		31								11.00		33.00					5.00		0.00											11.00		33.00				5.00		0.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00		33.00	5.00		0.00	11.00		33.00	5.00		0.00	11.00		11.00	25		25	25		0	25		25	25		0	25		25
H3706	024	0	1	01	01	H3706_024_0	6			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	1	2				30		100	30		31								47.00		141.00					41.00		82.00											47.00		141.00				41.00		82.00				47.00				47.00			1.57	1.37		1.57	1.37	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		82.00	35.00		105.00	35.00		82.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	024	0	1	01	01	H3706_024_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											85.98	50		50				72.89	40		40										50		50				40		40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	024	0	1	01	01	H3706_024_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											596.27	33						682.71	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3706	025	0	1	01	01	H3706_025_0	5			Preferred Generic	4	11	3	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								6.00		18.00					0.00		0.00											6.00		18.00				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																														
H3706	025	0	1	01	01	H3706_025_0	5			Generic	4	11	3	2	2	1		110	01		110	1				30		100	1	2				30		100	30		31								11.00		33.00					5.00		0.00											11.00		33.00				5.00		0.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00		33.00	5.00		0.00	11.00		33.00	5.00		0.00	11.00		11.00	25		25	25		0	25		25	25		0	25		25
H3706	025	0	1	01	01	H3706_025_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					41.00		82.00											47.00		141.00				41.00		82.00				47.00				47.00			1.57	1.37		1.57	1.37	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		82.00	35.00		105.00	35.00		82.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	025	0	1	01	01	H3706_025_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		100	1	2				30		100	30		31											73.65	50		50				67.10	40		40										50		50				40		40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H3706	025	0	1	01	01	H3706_025_0	5			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											643.27	33						628.31	33																							33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3727	001	2	1	01	01	H3727_001_2	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																			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	2			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	25	25	25				25	25	25				25		25
H3727	001	2	1	01	01	H3727_001_2	2			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	25	25	25				25	25	25				25		25
H3727	001	2	1	01	01	H3727_001_2	2			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	25	25	25				25	25	25				25		25
H3727	001	2	1	01	01	H3727_001_2	2			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	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																			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	2			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	25	25	25				25	25	25				25		25
H3727	001	3	1	01	01	H3727_001_3	2			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	25	25	25				25	25	25				25		25
H3727	001	3	1	01	01	H3727_001_3	2			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	25	25	25				25	25	25				25		25
H3727	001	3	1	01	01	H3727_001_3	2			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																														
H3748	003	0	1	01	01	H3748_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																														
H3748	003	0	1	01	01	H3748_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																														
H3748	003	0	1	01	01	H3748_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											57.96	24	24	24				94.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3748	003	0	1	01	01	H3748_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											38.13	25	25	25				42.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3748	003	0	1	01	01	H3748_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											559.01	25						626.13	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	25			25			25			25			25		25
H3755	001	0	1	01	01	H3755_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	0	0	0				0	0	0				0		0
H3755	001	0	1	01	01	H3755_001_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	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	25	25	25				25	25	25				25		25
H3755	001	0	1	01	01	H3755_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				81.13	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	70.00				35.00		35.00	20	20	20				20	20	20				20		20
H3755	001	0	1	01	01	H3755_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				122.59	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3755	001	0	1	01	01	H3755_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1347.60	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3755	004	0	1	01	01	H3755_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	0	0	0				0	0	0				0		0
H3755	004	0	1	01	01	H3755_004_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	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	25	25	25				0	0	0				25		25
H3755	004	0	1	01	01	H3755_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				74.16	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	70.00				35.00		35.00	20	20	20				20	20	20				20		20
H3755	004	0	1	01	01	H3755_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				83.20	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3755	004	0	1	01	01	H3755_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1536.88	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3755	005	0	1	01	01	H3755_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H3755	005	0	1	01	01	H3755_005_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	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	25	25	25				0	0	0				25		25
H3755	005	0	1	01	01	H3755_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				95.22	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	70.00				35.00		35.00	20	20	20				20	20	20				20		20
H3755	005	0	1	01	01	H3755_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				118.77	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3755	005	0	1	01	01	H3755_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1335.46	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3755	006	0	1	01	01	H3755_006_0	7		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	0	0	0				0	0	0				0		0
H3755	006	0	1	01	01	H3755_006_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				19.32	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3755	006	0	1	01	01	H3755_006_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				92.88	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	25	25	25				25	25	25				25		25
H3755	006	0	1	01	01	H3755_006_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				67.76	25	25	25																		25	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	25	25	25				25	25	25				25		25
H3755	006	0	1	01	01	H3755_006_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				820.33	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H3777	002	0	1	01	01	H3777_002_0	9			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3777	002	0	1	01	01	H3777_002_0	9			Generic	4	11	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, Select Care Drugs	4.00	8.00	12.00				4.00	8.00	12.00				4.00		4.00	25	25	25				25	25	25				25		25
H3777	002	0	1	01	01	H3777_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3777	002	0	1	01	01	H3777_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				57.87	27	27	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				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3777	002	0	1	01	01	H3777_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				559.50	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3777	002	0	1	01	01	H3777_002_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3794	002	0	1	02	01	H3794_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3794	002	0	1	02	01	H3794_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3794	002	0	1	02	01	H3794_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	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	25		25						25				25		25
H3794	002	0	1	02	01	H3794_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3794	002	0	1	02	01	H3794_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				367.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3794	004	0	1	02	01	H3794_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3794	004	0	1	02	01	H3794_004_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3794	004	0	1	02	01	H3794_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H3794	004	0	1	02	01	H3794_004_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3794	004	0	1	02	01	H3794_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				402.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3794	006	0	1	02	01	H3794_006_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3794	006	0	1	02	01	H3794_006_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3794	006	0	1	02	01	H3794_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H3794	006	0	1	02	01	H3794_006_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H3794	006	0	1	02	01	H3794_006_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				361.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	001	0	1	02	01	H3805_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	001	0	1	02	01	H3805_001_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	001	0	1	02	01	H3805_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H3805	001	0	1	02	01	H3805_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	001	0	1	02	01	H3805_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				426.00	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	25						25			25			25		25
H3805	015	0	1	02	01	H3805_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	015	0	1	02	01	H3805_015_0	4			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																														
H3805	015	0	1	02	01	H3805_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				41.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H3805	015	0	1	02	01	H3805_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				83.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	015	0	1	02	01	H3805_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				441.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	017	0	1	02	01	H3805_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	017	0	1	02	01	H3805_017_0	4			Generic	4	01	3	2	2	1	110		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																														
H3805	017	0	1	02	01	H3805_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				40.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H3805	017	0	1	02	01	H3805_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				83.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	017	0	1	02	01	H3805_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				424.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	032	0	1	02	01	H3805_032_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	032	0	1	02	01	H3805_032_0	4			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																														
H3805	032	0	1	02	01	H3805_032_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H3805	032	0	1	02	01	H3805_032_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				77.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	032	0	1	02	01	H3805_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				445.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	033	0	1	02	01	H3805_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	033	0	1	02	01	H3805_033_0	4			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																														
H3805	033	0	1	02	01	H3805_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				42.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H3805	033	0	1	02	01	H3805_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				87.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	033	0	1	02	01	H3805_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	034	0	1	02	01	H3805_034_0	3			Preferred Generic	4	01	1	2	1	1	110		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																														
H3805	034	0	1	02	01	H3805_034_0	3			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																														
H3805	034	0	1	02	01	H3805_034_0	3			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H3805	034	0	1	02	01	H3805_034_0	3			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				81.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	034	0	1	02	01	H3805_034_0	3			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				418.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	037	0	1	02	01	H3805_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	037	0	1	02	01	H3805_037_0	4			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																														
H3805	037	0	1	02	01	H3805_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H3805	037	0	1	02	01	H3805_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				73.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	037	0	1	02	01	H3805_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				438.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3805	039	1	1	02	01	H3805_039_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	039	1	1	02	01	H3805_039_1	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	039	1	1	02	01	H3805_039_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H3805	039	1	1	02	01	H3805_039_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	039	1	1	02	01	H3805_039_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				441.00	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	25						25			25			25		25
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	5.00		15.00																											15.00						0.00				5.00				5.00		0.17						0.16	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H3805	039	2	1	02	01	H3805_039_2	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				441.00	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	25						25			25			25		25
H3805	040	0	1	02	01	H3805_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	040	0	1	02	01	H3805_040_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	040	0	1	02	01	H3805_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H3805	040	0	1	02	01	H3805_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	46																										46						46					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	040	0	1	02	01	H3805_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				454.00	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	25						25			25			25		25
H3805	041	0	1	02	01	H3805_041_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	041	0	1	02	01	H3805_041_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	041	0	1	02	01	H3805_041_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H3805	041	0	1	02	01	H3805_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	041	0	1	02	01	H3805_041_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				433.00	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	25						25			25			25		25
H3805	043	0	1	02	01	H3805_043_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	043	0	1	02	01	H3805_043_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	043	0	1	02	01	H3805_043_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H3805	043	0	1	02	01	H3805_043_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	043	0	1	02	01	H3805_043_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				443.00	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	25						25			25			25		25
H3805	044	0	1	02	01	H3805_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	044	0	1	02	01	H3805_044_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	044	0	1	02	01	H3805_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H3805	044	0	1	02	01	H3805_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	044	0	1	02	01	H3805_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				403.00	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	25						25			25			25		25
H3805	045	0	1	02	01	H3805_045_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	045	0	1	02	01	H3805_045_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3805	045	0	1	02	01	H3805_045_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H3805	045	0	1	02	01	H3805_045_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H3805	045	0	1	02	01	H3805_045_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H3811	003	0	1	01	01	H3811_003_0	5		N	Preferred Generic	4	11	1	1	1	1	110		01	100		1	30		90				1	2			90				30		31				2.02	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H3811	003	0	1	01	01	H3811_003_0	5		N	Generic	4	11	1	1	2	1	110		01	100		1	30		90				1	2			90				30		31				4.22	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H3811	003	0	1	01	01	H3811_003_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		90				1	2			90				30		31				70.52	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H3811	003	0	1	01	01	H3811_003_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	30		90				1	2			90				30		31				42.83	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H3811	003	0	1	01	01	H3811_003_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				722.31	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3811	003	0	1	01	01	H3811_003_0	5		N	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																														
H3815	001	0	1	01	01	H3815_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	001	0	1	01	01	H3815_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	001	0	1	01	01	H3815_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	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	25	25	25				25	25	25				25		25
H3815	001	0	1	01	01	H3815_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	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	25	25	25				25	25	25				25		25
H3815	001	0	1	01	01	H3815_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				699.70	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	7			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	008	0	1	01	01	H3815_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	008	0	1	01	01	H3815_008_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	008	0	1	01	01	H3815_008_0	7			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	25	25	25				25	25	25				25		25
H3815	008	0	1	01	01	H3815_008_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	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	25	25	25				25	25	25				25		25
H3815	008	0	1	01	01	H3815_008_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				609.21	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	7			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	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	25	25	25				25	25	25				25		25
H3815	010	0	1	01	01	H3815_010_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	010	0	1	01	01	H3815_010_0	7			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	25	25	25				25	25	25				25		25
H3815	010	0	1	01	01	H3815_010_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				42.66	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		35.00	25	25	25				25	25	25				25		25
H3815	010	0	1	01	01	H3815_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				426.65	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	7			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	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	25	25	25				25	25	25				25		25
H3815	011	0	1	01	01	H3815_011_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																			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	25	25	25				25	25	25				25		25
H3815	011	0	1	01	01	H3815_011_0	7			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	25	25	25				25	25	25				25		25
H3815	011	0	1	01	01	H3815_011_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	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	25	25	25				25	25	25				25		25
H3815	011	0	1	01	01	H3815_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				578.41	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	7			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	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	25	25	25				25	25	25				25		25
H3815	013	0	1	01	01	H3815_013_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	013	0	1	01	01	H3815_013_0	7			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	25	25	25				25	25	25				25		25
H3815	013	0	1	01	01	H3815_013_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	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	25	25	25				25	25	25				25		25
H3815	013	0	1	01	01	H3815_013_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				569.52	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	7			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	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	25	25	25				25	25	25				25		25
H3815	016	0	1	02	01	H3815_016_0	7			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	25	25	25				25	25	25				25		25
H3815	016	0	1	02	01	H3815_016_0	7			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	25	25	25				25	25	25				25		25
H3815	016	0	1	02	01	H3815_016_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	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	25	25	25				25	25	25				25		25
H3815	016	0	1	02	01	H3815_016_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				583.14	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	7			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	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	25	25	25				25	25	25				25		25
H3815	019	0	1	01	01	H3815_019_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	019	0	1	01	01	H3815_019_0	7			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	25	25	25				25	25	25				25		25
H3815	019	0	1	01	01	H3815_019_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				46.69	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		35.00	25	25	25				25	25	25				25		25
H3815	019	0	1	01	01	H3815_019_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				673.44	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	7			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	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	25	25	25				25	25	25				25		25
H3815	020	0	1	01	01	H3815_020_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	020	0	1	01	01	H3815_020_0	7			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	25	25	25				25	25	25				25		25
H3815	020	0	1	01	01	H3815_020_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				49.19	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		35.00	25	25	25				25	25	25				25		25
H3815	020	0	1	01	01	H3815_020_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				674.07	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	7			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	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	25	25	25				25	25	25				25		25
H3815	021	0	1	01	01	H3815_021_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	021	0	1	01	01	H3815_021_0	7			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	25	25	25				25	25	25				25		25
H3815	021	0	1	01	01	H3815_021_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				50.73	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		35.00	25	25	25				25	25	25				25		25
H3815	021	0	1	01	01	H3815_021_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				726.14	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	7			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	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	25	25	25				25	25	25				25		25
H3815	023	0	1	01	01	H3815_023_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	023	0	1	01	01	H3815_023_0	7			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	25	25	25				25	25	25				25		25
H3815	023	0	1	01	01	H3815_023_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				49.76	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		35.00	25	25	25				25	25	25				25		25
H3815	023	0	1	01	01	H3815_023_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				763.61	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	7			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	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	25	25	25				25	25	25				25		25
H3815	028	0	1	01	01	H3815_028_0	7			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	25	25	25				25	25	25				25		25
H3815	028	0	1	01	01	H3815_028_0	7			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	25	25	25				25	25	25				25		25
H3815	028	0	1	01	01	H3815_028_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.81	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		35.00	25	25	25				25	25	25				25		25
H3815	028	0	1	01	01	H3815_028_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				731.09	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	7			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	030	0	1	01	01	H3815_030_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	030	0	1	01	01	H3815_030_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				3.89	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	030	0	1	01	01	H3815_030_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				70.76	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	030	0	1	01	01	H3815_030_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				43.55	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	030	0	1	01	01	H3815_030_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				555.34	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	030	0	1	01	01	H3815_030_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	031	0	1	01	01	H3815_031_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	25	25	25				25	25	25				25		25
H3815	031	0	1	01	01	H3815_031_0	7			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	25	25	25				25	25	25				25		25
H3815	031	0	1	01	01	H3815_031_0	7			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	25	25	25				25	25	25				25		25
H3815	031	0	1	01	01	H3815_031_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	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	25	25	25				25	25	25				25		25
H3815	031	0	1	01	01	H3815_031_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				599.03	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	7			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	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	25	25	25				25	25	25				25		25
H3815	033	0	1	01	01	H3815_033_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	033	0	1	01	01	H3815_033_0	6			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	25	25	25				25	25	25				25		25
H3815	033	0	1	01	01	H3815_033_0	6			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	25	25	25				25	25	25				25		25
H3815	033	0	1	01	01	H3815_033_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				542.63	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	6			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	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	25	25	25				25	25	25				25		25
H3815	034	0	1	01	01	H3815_034_0	7			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	25	25	25				25	25	25				25		25
H3815	034	0	1	01	01	H3815_034_0	7			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	25	25	25				25	25	25				25		25
H3815	034	0	1	01	01	H3815_034_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	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	25	25	25				25	25	25				25		25
H3815	034	0	1	01	01	H3815_034_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				612.78	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	7			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	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	25	25	25				25	25	25				25		25
H3815	035	0	1	01	01	H3815_035_0	7			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	25	25	25				25	25	25				25		25
H3815	035	0	1	01	01	H3815_035_0	7			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	25	25	25				25	25	25				25		25
H3815	035	0	1	01	01	H3815_035_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	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	25	25	25				25	25	25				25		25
H3815	035	0	1	01	01	H3815_035_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				746.45	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	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	038	0	1	01	01	H3815_038_0	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	25	25	25				25	25	25				25		25
H3815	038	0	1	01	01	H3815_038_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	038	0	1	01	01	H3815_038_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	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	25	25	25				25	25	25				25		25
H3815	038	0	1	01	01	H3815_038_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	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	25	25	25				25	25	25				25		25
H3815	038	0	1	01	01	H3815_038_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				449.25	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	7			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	039	0	1	01	01	H3815_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	25	25	25				25	25	25				25		25
H3815	039	0	1	01	01	H3815_039_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.07	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	25	25	25				25	25	25				25		25
H3815	039	0	1	01	01	H3815_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				76.46	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	039	0	1	01	01	H3815_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				54.30	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		35.00	25	25	25				25	25	25				25		25
H3815	039	0	1	01	01	H3815_039_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				447.60	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	039	0	1	01	01	H3815_039_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	040	0	1	01	01	H3815_040_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	25	25	25				25	25	25				25		25
H3815	040	0	1	01	01	H3815_040_0	7			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	25	25	25				25	25	25				25		25
H3815	040	0	1	01	01	H3815_040_0	7			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	25	25	25				25	25	25				25		25
H3815	040	0	1	01	01	H3815_040_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	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	25	25	25				25	25	25				25		25
H3815	040	0	1	01	01	H3815_040_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				440.48	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	7			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	041	0	1	01	01	H3815_041_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	25	25	25				25	25	25				25		25
H3815	041	0	1	01	01	H3815_041_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.84	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	041	0	1	01	01	H3815_041_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.80	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		35.00	25	25	25				25	25	25				25		25
H3815	041	0	1	01	01	H3815_041_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				49.17	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		35.00	25	25	25				25	25	25				25		25
H3815	041	0	1	01	01	H3815_041_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				549.90	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	041	0	1	01	01	H3815_041_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	042	0	1	01	01	H3815_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	25	25	25				25	25	25				25		25
H3815	042	0	1	01	01	H3815_042_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				6.02	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		35.00	25	25	25				25	25	25				25		25
H3815	042	0	1	01	01	H3815_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				70.09	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	042	0	1	01	01	H3815_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				44.28	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		35.00	25	25	25				25	25	25				25		25
H3815	042	0	1	01	01	H3815_042_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				496.96	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	042	0	1	01	01	H3815_042_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	044	0	1	01	01	H3815_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	044	0	1	01	01	H3815_044_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.05	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	044	0	1	01	01	H3815_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				78.30	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	25	25	25				25	25	25				25		25
H3815	044	0	1	01	01	H3815_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				52.58	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		35.00	25	25	25				25	25	25				25		25
H3815	044	0	1	01	01	H3815_044_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				431.71	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	044	0	1	01	01	H3815_044_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	045	0	1	01	01	H3815_045_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	25	25	25				25	25	25				25		25
H3815	045	0	1	01	01	H3815_045_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.07	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	25	25	25				25	25	25				25		25
H3815	045	0	1	01	01	H3815_045_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.19	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		35.00	25	25	25				25	25	25				25		25
H3815	045	0	1	01	01	H3815_045_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				52.75	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		35.00	25	25	25				25	25	25				25		25
H3815	045	0	1	01	01	H3815_045_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.57	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	045	0	1	01	01	H3815_045_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	046	0	1	01	01	H3815_046_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	25	25	25				25	25	25				25		25
H3815	046	0	1	01	01	H3815_046_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	25	25	25				25	25	25				25		25
H3815	046	0	1	01	01	H3815_046_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	25	25	25				25	25	25				25		25
H3815	046	0	1	01	01	H3815_046_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	25	25	25				25	25	25				25		25
H3815	046	0	1	01	01	H3815_046_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				590.68	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	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																														
H3815	047	0	1	01	01	H3815_047_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	25	25	25				25	25	25				25		25
H3815	047	0	1	01	01	H3815_047_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	047	0	1	01	01	H3815_047_0	7			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	25	25	25				25	25	25				25		25
H3815	047	0	1	01	01	H3815_047_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	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	25	25	25				25	25	25				25		25
H3815	047	0	1	01	01	H3815_047_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				592.97	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	7			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	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	25	25	25				25	25	25				25		25
H3815	048	0	1	01	01	H3815_048_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	048	0	1	01	01	H3815_048_0	7			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	25	25	25				25	25	25				25		25
H3815	048	0	1	01	01	H3815_048_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				55.59	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	048	0	1	01	01	H3815_048_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				592.52	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	7			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	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	25	25	25				25	25	25				25		25
H3815	049	0	1	01	01	H3815_049_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H3815	049	0	1	01	01	H3815_049_0	7			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	25	25	25				25	25	25				25		25
H3815	049	0	1	01	01	H3815_049_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	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	25	25	25				25	25	25				25		25
H3815	049	0	1	01	01	H3815_049_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				602.15	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	7			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	050	0	1	01	01	H3815_050_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	25	25	25				25	25	25				25		25
H3815	050	0	1	01	01	H3815_050_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	25	25	25				25	25	25				25		25
H3815	050	0	1	01	01	H3815_050_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	25	25	25				25	25	25				25		25
H3815	050	0	1	01	01	H3815_050_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	25	25	25				25	25	25				25		25
H3815	050	0	1	01	01	H3815_050_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				681.25	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	050	0	1	01	01	H3815_050_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																														
H3815	051	0	1	01	01	H3815_051_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	25	25	25				25	25	25				25		25
H3815	051	0	1	01	01	H3815_051_0	7			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				3.78	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		35.00	25	25	25				25	25	25				25		25
H3815	051	0	1	01	01	H3815_051_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.47	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		35.00	25	25	25				25	25	25				25		25
H3815	051	0	1	01	01	H3815_051_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				58.32	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		35.00	25	25	25				25	25	25				25		25
H3815	051	0	1	01	01	H3815_051_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				474.06	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	051	0	1	01	01	H3815_051_0	7			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																														
H3815	052	0	1	01	01	H3815_052_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	25	25	25				25	25	25				25		25
H3815	052	0	1	01	01	H3815_052_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				3.47	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		35.00	25	25	25				25	25	25				25		25
H3815	052	0	1	01	01	H3815_052_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				71.54	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	052	0	1	01	01	H3815_052_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				55.80	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		35.00	25	25	25				25	25	25				25		25
H3815	052	0	1	01	01	H3815_052_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				563.06	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	052	0	1	01	01	H3815_052_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	053	0	1	01	01	H3815_053_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	25	25	25				25	25	25				25		25
H3815	053	0	1	01	01	H3815_053_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	053	0	1	01	01	H3815_053_0	7			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	25	25	25				25	25	25				25		25
H3815	053	0	1	01	01	H3815_053_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	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	25	25	25				25	25	25				25		25
H3815	053	0	1	01	01	H3815_053_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				592.38	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	053	0	1	01	01	H3815_053_0	7			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	054	0	1	01	01	H3815_054_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	25	25	25				25	25	25				25		25
H3815	054	0	1	01	01	H3815_054_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	25	25	25				25	25	25				25		25
H3815	054	0	1	01	01	H3815_054_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	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	25	25	25				25	25	25				25		25
H3815	054	0	1	01	01	H3815_054_0	8			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				47.60	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		35.00	25	25	25				25	25	25				25		25
H3815	054	0	1	01	01	H3815_054_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				590.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	054	0	1	01	01	H3815_054_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																														
H3815	055	0	1	01	01	H3815_055_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	25	25	25				25	25	25				25		25
H3815	055	0	1	01	01	H3815_055_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	055	0	1	01	01	H3815_055_0	7			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	42.00	84.00	126.00																			42.00	84.00	126.00																42.00				42.00		1.40			1.40			1.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3815	055	0	1	01	01	H3815_055_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.11	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		35.00	25	25	25				25	25	25				25		25
H3815	055	0	1	01	01	H3815_055_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				606.20	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	055	0	1	01	01	H3815_055_0	7			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	056	0	1	01	01	H3815_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	056	0	1	01	01	H3815_056_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H3815	056	0	1	01	01	H3815_056_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	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	25	25	25				25	25	25				25		25
H3815	056	0	1	01	01	H3815_056_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.57	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		35.00	25	25	25				25	25	25				25		25
H3815	056	0	1	01	01	H3815_056_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				483.58	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3815	056	0	1	01	01	H3815_056_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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																														
H3817	008	1	1	04	01	H3817_008_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	1	1	04	01	H3817_008_1	6			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					5.00	10.00	10.00											10.00	20.00	20.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	20.00	5.00	10.00	10.00	10.00	20.00	20.00	5.00	10.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	1	1	04	01	H3817_008_1	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.16	22	22	22				26.16	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	22	22	22	19	19	19	22	22	22	19	19	19	22		22
H3817	008	1	1	04	01	H3817_008_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											56.98	38	38	38				56.98	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	1	1	04	01	H3817_008_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											679.32	25						679.32	25												25						25					25			25								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	20.00	5.00	10.00	10.00	10.00	20.00	20.00	5.00	10.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											26.16	22	22	22				26.16	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	22	22	22	19	19	19	22	22	22	19	19	19	22		22
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											56.98	38	38	38				56.98	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											679.32	25						679.32	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3817	008	4	1	04	01	H3817_008_4	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	4	1	04	01	H3817_008_4	6			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					5.00	10.00	10.00											10.00	20.00	20.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	20.00	5.00	10.00	10.00	10.00	20.00	20.00	5.00	10.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	4	1	04	01	H3817_008_4	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.16	22	22	22				26.16	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	22	22	22	19	19	19	22	22	22	19	19	19	22		22
H3817	008	4	1	04	01	H3817_008_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											56.98	38	38	38				56.98	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	008	4	1	04	01	H3817_008_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											679.32	25						679.32	25												25						25					25			25								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								6.00	12.00	12.00					3.00	6.00	6.00											6.00	12.00	12.00				3.00	6.00	0.00				6.00				6.00			0.20	0.10		0.20	0.10	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	12.00	3.00	6.00	6.00	6.00	12.00	12.00	3.00	6.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											30.55	23	23	23				30.55	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	23	23	23	20	20	20	23	23	23	20	20	20	23		23
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											69.15	38	38	38				69.15	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											825.42	30						825.42	30												30						30					30			30								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								6.00	12.00	12.00					3.00	6.00	6.00											6.00	12.00	12.00				3.00	6.00	0.00				6.00				6.00			0.20	0.10		0.20	0.10	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	12.00	3.00	6.00	6.00	6.00	12.00	12.00	3.00	6.00	0.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											30.55	23	23	23				30.55	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	23	23	23	20	20	20	23	23	23	20	20	20	23		23
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											69.15	38	38	38				69.15	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											825.42	30						825.42	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3817	011	1	1	04	01	H3817_011_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	1	1	04	01	H3817_011_1	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	1	1	04	01	H3817_011_1	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	1	1	04	01	H3817_011_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											41.33	32	32	32				41.33	27	27	27										32	32	32				27	27	27			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	1	1	04	01	H3817_011_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											647.52	25						647.52	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3817	011	2	1	04	01	H3817_011_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	2	1	04	01	H3817_011_2	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	2	1	04	01	H3817_011_2	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	2	1	04	01	H3817_011_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											41.33	32	32	32				41.33	27	27	27										32	32	32				27	27	27			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	2	1	04	01	H3817_011_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											647.52	25						647.52	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3817	011	3	1	04	01	H3817_011_3	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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	3	1	04	01	H3817_011_3	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	3	1	04	01	H3817_011_3	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	60.00					15.00	30.00	45.00											20.00	40.00	60.00				15.00	30.00	45.00				20.00				20.00			0.67	0.50		0.67	0.50	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	15.00	30.00	45.00	20.00	40.00	60.00	15.00	30.00	45.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	3	1	04	01	H3817_011_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.33	32	32	32				41.33	27	27	27										32	32	32				27	27	27			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3817	011	3	1	04	01	H3817_011_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											647.52	25						647.52	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	001	0	1	01	01	H3822_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	001	0	1	01	01	H3822_001_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	001	0	1	01	01	H3822_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											61.17	22	22	22				50.37	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	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22	19	19	19	22	22	22	19	19	19	22		22
H3822	001	0	1	01	01	H3822_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											88.26	44	44	44				86.80	40	40	40										44	44	44				40	40	40			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	001	0	1	01	01	H3822_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											669.86	27						614.85	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	002	0	1	01	01	H3822_002_0	5			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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	002	0	1	01	01	H3822_002_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	002	0	1	01	01	H3822_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											50.51	20	20	20				44.14	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H3822	002	0	1	01	01	H3822_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											62.09	42	42	42				70.44	39	39	39										42	42	42				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	002	0	1	01	01	H3822_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											491.69	27						512.29	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	007	0	1	02	01	H3822_007_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	007	0	1	02	01	H3822_007_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	007	0	1	02	01	H3822_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											55.13	22	22	22				45.44	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	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22	18	18	18	22	22	22	18	18	18	22		22
H3822	007	0	1	02	01	H3822_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											85.90	43	43	43				86.01	39	39	39										43	43	43				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	007	0	1	02	01	H3822_007_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											662.00	27						597.75	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	008	0	1	02	01	H3822_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	008	0	1	02	01	H3822_008_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	008	0	1	02	01	H3822_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											46.36	19	19	19				43.09	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H3822	008	0	1	02	01	H3822_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											87.32	43	43	43				83.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	008	0	1	02	01	H3822_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											627.18	27						628.93	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	012	0	1	01	01	H3822_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	012	0	1	01	01	H3822_012_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	012	0	1	01	01	H3822_012_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											49.35	19	19	19				47.60	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H3822	012	0	1	01	01	H3822_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											76.94	41	41	41				78.07	38	38	38										41	41	41				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	012	0	1	01	01	H3822_012_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											651.72	27						604.58	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3822	014	0	1	01	01	H3822_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	014	0	1	01	01	H3822_014_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	014	0	1	01	01	H3822_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											48.42	19	19	19				45.53	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H3822	014	0	1	01	01	H3822_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											81.29	42	42	42				77.04	38	38	38										42	42	42				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3822	014	0	1	01	01	H3822_014_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											560.51	27						555.52	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3828	001	0	1	04	01	H3828_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	25	25	25	0	0	0	0	0	0				25		25
H3828	001	0	1	04	01	H3828_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	25	25	25	25	25	25	0	0	0				25		25
H3828	001	0	1	04	01	H3828_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											35.13	25	25	25				40.06	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H3828	001	0	1	04	01	H3828_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											57.60	30	30	30				56.69	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	25	25	25	25	25	25	25	25	25				25		25
H3828	001	0	1	04	01	H3828_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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	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	25	25	25				25	25	25				25		25
H3832	007	0	1	04	01	H3832_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				41.71	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	20	20	20				20	20	20				20		20
H3832	007	0	1	04	01	H3832_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				77.21	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	25	25	25				25	25	25				25		25
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				494.85	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3832	008	0	1	04	01	H3832_008_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H3832	008	0	1	04	01	H3832_008_0	7			Generic	4	01	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	11.00	22.00	33.00																			11.00	11.00	11.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00				11.00	11.00	11.00				11.00		11.00	25	25	25				25	25	25				25		25
H3832	008	0	1	04	01	H3832_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				37.74	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	20	20	20				20	20	20				20		20
H3832	008	0	1	04	01	H3832_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				67.55	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	25	25	25				25	25	25				25		25
H3832	008	0	1	04	01	H3832_008_0	7			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				457.99	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3832	009	0	1	04	01	H3832_009_0	5			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	0	0	0				0	0	0				0		0
H3832	009	0	1	04	01	H3832_009_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	25	25	25				25	25	25				25		25
H3832	009	0	1	04	01	H3832_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				46.08	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	20	20	20				20	20	20				20		20
H3832	009	0	1	04	01	H3832_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				84.99	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	25	25	25				25	25	25				25		25
H3832	009	0	1	04	01	H3832_009_0	5			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				608.14	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
H3832	010	0	1	04	01	H3832_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				39.35	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	20	20	20				20	20	20				20		20
H3832	010	0	1	04	01	H3832_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				77.85	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	25	25	25				25	25	25				25		25
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				511.68	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	0.00	0.00	0.00																			0.00	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	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	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																														
H3864	006	0	1	01	01	H3864_006_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				79.27	24	24	24																		15	15	15															24			24								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	24	24	24				15	15	15				24		24
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				32.37	28	28	28																		28	28	28															28			28								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				56.06	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																			0.00	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	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	10.00	20.00	30.00																			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																														
H3864	014	0	1	02	01	H3864_014_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				80.17	24	24	24																		15	15	15															24			24								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	24	24	24				15	15	15				24		24
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				35.38	28	28	28																		28	28	28															28			28								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				63.14	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3864	024	0	1	02	01	H3864_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																														
H3864	024	0	1	02	01	H3864_024_0	6			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	6.00	6.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	024	0	1	02	01	H3864_024_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				70.63	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
H3864	024	0	1	02	01	H3864_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				32.33	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	024	0	1	02	01	H3864_024_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				58.21	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																			0.00	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	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	8.00	16.00	24.00																			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																														
H3864	027	0	1	01	01	H3864_027_0	5			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.09	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
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				32.84	25	25	25																		25	25	25															25			25								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				102.30	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3864	029	0	1	02	01	H3864_029_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																														
H3864	029	0	1	02	01	H3864_029_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																			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																														
H3864	029	0	1	02	01	H3864_029_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				72.06	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
H3864	029	0	1	02	01	H3864_029_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				27.68	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	029	0	1	02	01	H3864_029_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				88.68	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																			0.00	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	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	10.00	20.00	30.00																			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																														
H3864	034	0	1	02	01	H3864_034_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				91.83	24	24	24																		15	15	15															24			24								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	24	24	24				15	15	15				24		24
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				33.01	28	28	28																		28	28	28															28			28								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				79.97	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																			0.00	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	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	6.00	12.00	18.00																			6.00	6.00	6.00																6.00				6.00		0.20			0.20			0.19	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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				76.09	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
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				32.37	25	25	25																		25	25	25															25			25								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				83.02	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3864	040	0	1	01	01	H3864_040_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																														
H3864	040	0	1	01	01	H3864_040_0	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	6.00	6.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	040	0	1	01	01	H3864_040_0	6			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				87.39	24	24	24																		15	15	15															24			24								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	24	24	24				15	15	15				24		24
H3864	040	0	1	01	01	H3864_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				33.05	28	28	28																		28	28	28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	040	0	1	01	01	H3864_040_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				88.39	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0.00	0.00	0.00																			0.00	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	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	6.00	12.00	18.00																			6.00	6.00	6.00																6.00				6.00		0.20			0.20			0.19	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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				70.04	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
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				32.37	25	25	25																		25	25	25															25			25								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				78.67	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3864	043	0	1	01	01	H3864_043_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	043	0	1	01	01	H3864_043_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				5.26	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	7		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				100.16	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3864	043	0	1	01	01	H3864_043_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				33.18	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	043	0	1	01	01	H3864_043_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				133.30	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3864	045	0	1	01	01	H3864_045_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	045	0	1	01	01	H3864_045_0	7		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				5.51	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	045	0	1	01	01	H3864_045_0	7		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				99.06	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3864	045	0	1	01	01	H3864_045_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				36.13	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3864	045	0	1	01	01	H3864_045_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				148.83	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3868	001	0	1	02	01	H3868_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H3868	001	0	1	02	01	H3868_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3868	001	0	1	02	01	H3868_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	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	25		25						25				25		25
H3868	001	0	1	02	01	H3868_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				60.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3868	001	0	1	02	01	H3868_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3890	001	0	1	04	01	H3890_001_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H3890	001	0	1	04	01	H3890_001_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H3890	001	0	1	04	01	H3890_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				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	25	25	25				25	25	25				25		25
H3890	001	0	1	04	01	H3890_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				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	25	25	25				25	25	25				25		25
H3890	001	0	1	04	01	H3890_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				747.33	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	6.00	9.00	12.00																			6.00	9.00	12.00																6.00				6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	9.00	12.00				6.00	9.00	12.00				6.00		6.00	25	25	25				25	25	25				25		25
H3890	005	0	1	04	01	H3890_005_0	10			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	67.50	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	52.50	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3907	006	0	1	01	01	H3907_006_0	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	006	0	1	01	01	H3907_006_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	006	0	1	01	01	H3907_006_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.38	25	25	25				40.43	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	006	0	1	01	01	H3907_006_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.37	50	50	50				23.70	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	006	0	1	01	01	H3907_006_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1330.26	33						802.92	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	037	0	1	01	01	H3907_037_0	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	037	0	1	01	01	H3907_037_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	037	0	1	01	01	H3907_037_0	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											37.76	25	25	25				59.20	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	037	0	1	01	01	H3907_037_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											36.79	49	49	49				28.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	037	0	1	01	01	H3907_037_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1511.79	31						644.95	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	1	1	01	01	H3907_057_1	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	1	1	01	01	H3907_057_1	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	1	1	01	01	H3907_057_1	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	1	1	01	01	H3907_057_1	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	1	1	01	01	H3907_057_1	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	2	1	01	01	H3907_057_2	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	2	1	01	01	H3907_057_2	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	2	1	01	01	H3907_057_2	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	2	1	01	01	H3907_057_2	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	2	1	01	01	H3907_057_2	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	3	1	01	01	H3907_057_3	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	3	1	01	01	H3907_057_3	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	3	1	01	01	H3907_057_3	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	3	1	01	01	H3907_057_3	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	3	1	01	01	H3907_057_3	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	4	1	01	01	H3907_057_4	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	4	1	01	01	H3907_057_4	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	4	1	01	01	H3907_057_4	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	4	1	01	01	H3907_057_4	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	4	1	01	01	H3907_057_4	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	5	1	01	01	H3907_057_5	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	5	1	01	01	H3907_057_5	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	5	1	01	01	H3907_057_5	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	5	1	01	01	H3907_057_5	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	5	1	01	01	H3907_057_5	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	6	1	01	01	H3907_057_6	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	6	1	01	01	H3907_057_6	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	6	1	01	01	H3907_057_6	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	6	1	01	01	H3907_057_6	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	6	1	01	01	H3907_057_6	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	057	7	1	01	01	H3907_057_7	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	7	1	01	01	H3907_057_7	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	057	7	1	01	01	H3907_057_7	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											40.62	25	25	25				60.22	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	7	1	01	01	H3907_057_7	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.45	49	49	49				30.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	057	7	1	01	01	H3907_057_7	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1350.02	31						614.82	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	058	1	1	01	01	H3907_058_1	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	1	1	01	01	H3907_058_1	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	1	1	01	01	H3907_058_1	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											30.69	25	25	25				41.74	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	1	1	01	01	H3907_058_1	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											31.27	50	50	50				23.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	1	1	01	01	H3907_058_1	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1367.00	33						709.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	058	2	1	01	01	H3907_058_2	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	2	1	01	01	H3907_058_2	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	2	1	01	01	H3907_058_2	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											30.69	25	25	25				41.74	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	2	1	01	01	H3907_058_2	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											31.27	50	50	50				23.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	2	1	01	01	H3907_058_2	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1367.00	33						709.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	058	3	1	01	01	H3907_058_3	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	3	1	01	01	H3907_058_3	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	058	3	1	01	01	H3907_058_3	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											30.69	25	25	25				41.74	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	3	1	01	01	H3907_058_3	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											31.27	50	50	50				23.60	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	058	3	1	01	01	H3907_058_3	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1367.00	33						709.74	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	059	1	1	01	01	H3907_059_1	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	1	1	01	01	H3907_059_1	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	1	1	01	01	H3907_059_1	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.64	24	24	24				58.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3907	059	1	1	01	01	H3907_059_1	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											25.91	31	31	31				22.90	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	059	1	1	01	01	H3907_059_1	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1328.29	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	059	2	1	01	01	H3907_059_2	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	2	1	01	01	H3907_059_2	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	2	1	01	01	H3907_059_2	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.64	24	24	24				58.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3907	059	2	1	01	01	H3907_059_2	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											25.91	31	31	31				22.90	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	059	2	1	01	01	H3907_059_2	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1328.29	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	059	3	1	01	01	H3907_059_3	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	3	1	01	01	H3907_059_3	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	3	1	01	01	H3907_059_3	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.64	24	24	24				58.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3907	059	3	1	01	01	H3907_059_3	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											25.91	31	31	31				22.90	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	059	3	1	01	01	H3907_059_3	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1328.29	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	059	4	1	01	01	H3907_059_4	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	4	1	01	01	H3907_059_4	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	4	1	01	01	H3907_059_4	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.64	24	24	24				58.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3907	059	4	1	01	01	H3907_059_4	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											25.91	31	31	31				22.90	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	059	4	1	01	01	H3907_059_4	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1328.29	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3907	059	5	1	01	01	H3907_059_5	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	5	1	01	01	H3907_059_5	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H3907	059	5	1	01	01	H3907_059_5	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.64	24	24	24				58.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3907	059	5	1	01	01	H3907_059_5	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											25.91	31	31	31				22.90	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3907	059	5	1	01	01	H3907_059_5	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1328.29	29						592.71	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3909	001	0	1	04	01	H3909_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	18.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3909	001	0	1	04	01	H3909_001_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	40.00					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	6			Preferred Brand	4	11	1	1	3	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								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H3909	001	0	1	04	01	H3909_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											60.00	33	33	33				51.00	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	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3909	001	0	1	04	01	H3909_001_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3909	009	0	1	04	01	H3909_009_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	18.00					0.00	0.00	0.00					0.00	0.00	0.00																9.00				9.00			0.30	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3909	009	0	1	04	01	H3909_009_0	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	40.00					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	6			Preferred Brand	4	11	1	1	3	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								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H3909	009	0	1	04	01	H3909_009_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											60.00	33	33	33				44.00	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	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3909	009	0	1	04	01	H3909_009_0	6			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	18.00					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	40.00					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											46.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											64.00	38	38	38				53.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H3909	020	0	1	04	01	H3909_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	18.00					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	020	0	1	04	01	H3909_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	40.00					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	020	0	1	04	01	H3909_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											61.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3909	020	0	1	04	01	H3909_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											77.00	30	30	30				57.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3909	020	0	1	04	01	H3909_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												28	28	28					28	28	28				28	28	28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3916	001	0	1	04	01	H3916_001_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	001	0	1	04	01	H3916_001_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	001	0	1	04	01	H3916_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					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	20		20	20		20			20			20	20		20
H3916	001	0	1	04	01	H3916_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					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	20		20	20		20			20			20	20		20
H3916	001	0	1	04	01	H3916_001_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	002	0	1	04	01	H3916_002_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	002	0	1	04	01	H3916_002_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	002	0	1	04	01	H3916_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					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	20		20	20		20			20			20	20		20
H3916	002	0	1	04	01	H3916_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					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	20		20	20		20			20			20	20		20
H3916	002	0	1	04	01	H3916_002_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																														
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	20		20	20		20			20			20	20		20
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	20		20	20		20			20			20	20		20
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	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	015	0	1	04	01	H3916_015_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	015	0	1	04	01	H3916_015_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	20		20	20		20			20			20	20		20
H3916	015	0	1	04	01	H3916_015_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	20		20	20		20			20			20	20		20
H3916	015	0	1	04	01	H3916_015_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	018	0	1	04	01	H3916_018_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	018	0	1	04	01	H3916_018_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	018	0	1	04	01	H3916_018_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	20		20	20		20			20			20	20		20
H3916	018	0	1	04	01	H3916_018_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											77.58	30		30				77.58	30		30												30						30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	018	0	1	04	01	H3916_018_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	022	0	1	04	01	H3916_022_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	022	0	1	04	01	H3916_022_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	022	0	1	04	01	H3916_022_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	20		20	20		20			20			20	20		20
H3916	022	0	1	04	01	H3916_022_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	20		20	20		20			20			20	20		20
H3916	022	0	1	04	01	H3916_022_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	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	20		20	20		20			20			20	20		20
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	20		20	20		20			20			20	20		20
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	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	032	0	1	04	01	H3916_032_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	032	0	1	04	01	H3916_032_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	20		20	20		20			20			20	20		20
H3916	032	0	1	04	01	H3916_032_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											97.38	35		35				97.38	35		35												35						35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	032	0	1	04	01	H3916_032_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	033	0	1	04	01	H3916_033_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	033	0	1	04	01	H3916_033_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	033	0	1	04	01	H3916_033_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	20		20	20		20			20			20	20		20
H3916	033	0	1	04	01	H3916_033_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											87.47	35		35				87.47	35		35												35						35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	033	0	1	04	01	H3916_033_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	035	1	1	04	01	H3916_035_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	035	1	1	04	01	H3916_035_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	035	1	1	04	01	H3916_035_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											71.82	20		20				71.82	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	035	1	1	04	01	H3916_035_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											86.34	30		30				86.34	30		30												30						30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	035	1	1	04	01	H3916_035_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	035	2	1	04	01	H3916_035_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	035	2	1	04	01	H3916_035_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	035	2	1	04	01	H3916_035_2	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											71.82	20		20				71.82	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	035	2	1	04	01	H3916_035_2	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											86.34	30		30				86.34	30		30												30						30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	035	2	1	04	01	H3916_035_2	7			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	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					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				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											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								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					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				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											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	037	5	1	04	01	H3916_037_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	037	5	1	04	01	H3916_037_5	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	037	5	1	04	01	H3916_037_5	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	037	5	1	04	01	H3916_037_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
H3916	037	5	1	04	01	H3916_037_5	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	037	6	1	04	01	H3916_037_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																														
H3916	037	6	1	04	01	H3916_037_6	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	037	6	1	04	01	H3916_037_6	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	037	6	1	04	01	H3916_037_6	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
H3916	037	6	1	04	01	H3916_037_6	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	037	7	1	04	01	H3916_037_7	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	7	1	04	01	H3916_037_7	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	037	7	1	04	01	H3916_037_7	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	037	7	1	04	01	H3916_037_7	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
H3916	037	7	1	04	01	H3916_037_7	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	037	8	1	04	01	H3916_037_8	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	8	1	04	01	H3916_037_8	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	037	8	1	04	01	H3916_037_8	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.35	23		23				80.35	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	037	8	1	04	01	H3916_037_8	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.83	25		25				67.83	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	20		20	20		20			20			20	20		20
H3916	037	8	1	04	01	H3916_037_8	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	038	0	1	04	01	H3916_038_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	038	0	1	04	01	H3916_038_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	038	0	1	04	01	H3916_038_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.92	20		20				69.92	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	038	0	1	04	01	H3916_038_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											81.73	30		30				81.73	30		30												30						30			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	038	0	1	04	01	H3916_038_0	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	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					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				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											79.70	23		23				79.70	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											65.97	25		25				65.97	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	041	1	1	04	01	H3916_041_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	041	1	1	04	01	H3916_041_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	041	1	1	04	01	H3916_041_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.62	20		20				69.62	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	1	1	04	01	H3916_041_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											82.32	29		29				82.32	29		29												29						29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	1	1	04	01	H3916_041_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	041	2	1	04	01	H3916_041_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	041	2	1	04	01	H3916_041_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	041	2	1	04	01	H3916_041_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.62	20		20				69.62	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	2	1	04	01	H3916_041_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											82.32	29		29				82.32	29		29												29						29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	2	1	04	01	H3916_041_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	041	3	1	04	01	H3916_041_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	041	3	1	04	01	H3916_041_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	041	3	1	04	01	H3916_041_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.62	20		20				69.62	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	3	1	04	01	H3916_041_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											82.32	29		29				82.32	29		29												29						29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3916	041	3	1	04	01	H3916_041_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	057	0	1	04	01	H3916_057_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	057	0	1	04	01	H3916_057_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	057	0	1	04	01	H3916_057_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											82.76	23		23				82.76	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	057	0	1	04	01	H3916_057_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.46	25		25				72.46	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	20		20	20		20			20			20	20		20
H3916	057	0	1	04	01	H3916_057_0	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	058	0	1	04	01	H3916_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													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	058	0	1	04	01	H3916_058_0	5			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	058	0	1	04	01	H3916_058_0	5			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											83.14	23		23				83.14	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	058	0	1	04	01	H3916_058_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											73.16	25		25				73.16	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	20		20	20		20			20			20	20		20
H3916	058	0	1	04	01	H3916_058_0	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																														
H3916	059	1	1	04	01	H3916_059_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	059	1	1	04	01	H3916_059_1	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	059	1	1	04	01	H3916_059_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											83.14	23		23				83.14	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	059	1	1	04	01	H3916_059_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											73.16	25		25				73.16	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	20		20	20		20			20			20	20		20
H3916	059	1	1	04	01	H3916_059_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	059	2	1	04	01	H3916_059_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	059	2	1	04	01	H3916_059_2	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	059	2	1	04	01	H3916_059_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											83.14	23		23				83.14	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	059	2	1	04	01	H3916_059_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											73.16	25		25				73.16	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	20		20	20		20			20			20	20		20
H3916	059	2	1	04	01	H3916_059_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	060	1	1	04	01	H3916_060_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	060	1	1	04	01	H3916_060_1	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	1	1	04	01	H3916_060_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	1	1	04	01	H3916_060_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	1	1	04	01	H3916_060_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	060	2	1	04	01	H3916_060_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	060	2	1	04	01	H3916_060_2	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	2	1	04	01	H3916_060_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	2	1	04	01	H3916_060_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	2	1	04	01	H3916_060_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	060	3	1	04	01	H3916_060_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	060	3	1	04	01	H3916_060_3	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	3	1	04	01	H3916_060_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	3	1	04	01	H3916_060_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	3	1	04	01	H3916_060_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	060	4	1	04	01	H3916_060_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	060	4	1	04	01	H3916_060_4	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	4	1	04	01	H3916_060_4	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	4	1	04	01	H3916_060_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	4	1	04	01	H3916_060_4	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	060	5	1	04	01	H3916_060_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	060	5	1	04	01	H3916_060_5	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	5	1	04	01	H3916_060_5	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	5	1	04	01	H3916_060_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	5	1	04	01	H3916_060_5	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	060	6	1	04	01	H3916_060_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																														
H3916	060	6	1	04	01	H3916_060_6	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	060	6	1	04	01	H3916_060_6	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	060	6	1	04	01	H3916_060_6	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	060	6	1	04	01	H3916_060_6	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	061	1	1	04	01	H3916_061_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	061	1	1	04	01	H3916_061_1	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	061	1	1	04	01	H3916_061_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	061	1	1	04	01	H3916_061_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	061	1	1	04	01	H3916_061_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	061	2	1	04	01	H3916_061_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	061	2	1	04	01	H3916_061_2	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	061	2	1	04	01	H3916_061_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	061	2	1	04	01	H3916_061_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	061	2	1	04	01	H3916_061_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	062	0	1	04	01	H3916_062_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	062	0	1	04	01	H3916_062_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	062	0	1	04	01	H3916_062_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.32	23		23				80.32	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	062	0	1	04	01	H3916_062_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.54	25		25				68.54	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	20		20	20		20			20			20	20		20
H3916	062	0	1	04	01	H3916_062_0	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	063	0	1	04	01	H3916_063_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	063	0	1	04	01	H3916_063_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	063	0	1	04	01	H3916_063_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.33	23		23				80.33	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	063	0	1	04	01	H3916_063_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.53	25		25				68.53	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	20		20	20		20			20			20	20		20
H3916	063	0	1	04	01	H3916_063_0	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	064	0	1	04	01	H3916_064_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	064	0	1	04	01	H3916_064_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	064	0	1	04	01	H3916_064_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											79.93	23		23				79.93	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	064	0	1	04	01	H3916_064_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.94	25		25				67.94	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	20		20	20		20			20			20	20		20
H3916	064	0	1	04	01	H3916_064_0	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	065	0	1	04	01	H3916_065_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	065	0	1	04	01	H3916_065_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3916	065	0	1	04	01	H3916_065_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											80.33	23		23				80.33	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	065	0	1	04	01	H3916_065_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.53	25		25				68.53	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	20		20	20		20			20			20	20		20
H3916	065	0	1	04	01	H3916_065_0	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	066	0	1	04	01	H3916_066_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	066	0	1	04	01	H3916_066_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	066	0	1	04	01	H3916_066_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											79.93	23		23				79.93	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3916	066	0	1	04	01	H3916_066_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.94	25		25				67.94	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	20		20	20		20			20			20	20		20
H3916	066	0	1	04	01	H3916_066_0	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																														
H3923	013	0	1	04	01	H3923_013_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	013	0	1	04	01	H3923_013_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											97.02	44	44	44				98.67	44	44	44										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	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											810.03	31						622.67	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	25			25			25			25			25		25
H3923	017	0	1	04	01	H3923_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	017	0	1	04	01	H3923_017_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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	017	0	1	04	01	H3923_017_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	017	0	1	04	01	H3923_017_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	017	0	1	04	01	H3923_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											728.06	31						702.86	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	25			25			25			25			25		25
H3923	044	1	1	04	01	H3923_044_1	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	1	1	04	01	H3923_044_1	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	1	1	04	01	H3923_044_1	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.51	19	19	19				28.89	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3923	044	1	1	04	01	H3923_044_1	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											57.01	40	40	40				70.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	1	1	04	01	H3923_044_1	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											391.45	28						491.21	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3923	044	2	1	04	01	H3923_044_2	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	2	1	04	01	H3923_044_2	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	2	1	04	01	H3923_044_2	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.51	19	19	19				28.89	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3923	044	2	1	04	01	H3923_044_2	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											57.01	40	40	40				70.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	2	1	04	01	H3923_044_2	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											391.45	28						491.21	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3923	044	3	1	04	01	H3923_044_3	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	3	1	04	01	H3923_044_3	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	3	1	04	01	H3923_044_3	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.51	19	19	19				28.89	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3923	044	3	1	04	01	H3923_044_3	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											57.01	40	40	40				70.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	3	1	04	01	H3923_044_3	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											391.45	28						491.21	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3923	044	4	1	04	01	H3923_044_4	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	4	1	04	01	H3923_044_4	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	4	1	04	01	H3923_044_4	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											29.51	19	19	19				28.89	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3923	044	4	1	04	01	H3923_044_4	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											57.01	40	40	40				70.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	044	4	1	04	01	H3923_044_4	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											391.45	28						491.21	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3923	045	1	1	04	01	H3923_045_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				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	1	1	04	01	H3923_045_1	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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	1	1	04	01	H3923_045_1	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											23.70	16	16	16				24.75	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	045	1	1	04	01	H3923_045_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											63.52	39	39	39				65.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	1	1	04	01	H3923_045_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											489.41	26						536.38	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	25			25			25			25			25		25
H3923	045	2	1	04	01	H3923_045_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				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	2	1	04	01	H3923_045_2	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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	2	1	04	01	H3923_045_2	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											23.70	16	16	16				24.75	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	045	2	1	04	01	H3923_045_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											63.52	39	39	39				65.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	2	1	04	01	H3923_045_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											489.41	26						536.38	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	25			25			25			25			25		25
H3923	045	3	1	04	01	H3923_045_3	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				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	3	1	04	01	H3923_045_3	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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	3	1	04	01	H3923_045_3	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											23.70	16	16	16				24.75	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	045	3	1	04	01	H3923_045_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											63.52	39	39	39				65.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	3	1	04	01	H3923_045_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											489.41	26						536.38	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	25			25			25			25			25		25
H3923	045	4	1	04	01	H3923_045_4	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				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	4	1	04	01	H3923_045_4	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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	4	1	04	01	H3923_045_4	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											23.70	16	16	16				24.75	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	045	4	1	04	01	H3923_045_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											63.52	39	39	39				65.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	4	1	04	01	H3923_045_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											489.41	26						536.38	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	25			25			25			25			25		25
H3923	045	5	1	04	01	H3923_045_5	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				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	5	1	04	01	H3923_045_5	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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	5	1	04	01	H3923_045_5	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											23.70	16	16	16				24.75	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	045	5	1	04	01	H3923_045_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											63.52	39	39	39				65.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	045	5	1	04	01	H3923_045_5	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											489.41	26						536.38	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	25			25			25			25			25		25
H3923	046	1	1	04	01	H3923_046_1	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	1	1	04	01	H3923_046_1	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	1	1	04	01	H3923_046_1	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.13	20	20	20				26.16	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3923	046	1	1	04	01	H3923_046_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											67.05	42	42	42				63.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	1	1	04	01	H3923_046_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.55	29						502.61	29												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	25			25			25			25			25		25
H3923	046	2	1	04	01	H3923_046_2	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	2	1	04	01	H3923_046_2	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	2	1	04	01	H3923_046_2	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.13	20	20	20				26.16	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3923	046	2	1	04	01	H3923_046_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											67.05	42	42	42				63.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	2	1	04	01	H3923_046_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.55	29						502.61	29												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	25			25			25			25			25		25
H3923	046	3	1	04	01	H3923_046_3	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	3	1	04	01	H3923_046_3	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	3	1	04	01	H3923_046_3	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.13	20	20	20				26.16	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3923	046	3	1	04	01	H3923_046_3	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											67.05	42	42	42				63.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	3	1	04	01	H3923_046_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.55	29						502.61	29												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	25			25			25			25			25		25
H3923	046	4	1	04	01	H3923_046_4	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	4	1	04	01	H3923_046_4	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	4	1	04	01	H3923_046_4	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											26.13	20	20	20				26.16	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H3923	046	4	1	04	01	H3923_046_4	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											67.05	42	42	42				63.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	046	4	1	04	01	H3923_046_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.55	29						502.61	29												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	25			25			25			25			25		25
H3923	047	1	1	04	01	H3923_047_1	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	1	1	04	01	H3923_047_1	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	1	1	04	01	H3923_047_1	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.81	18	18	18				20.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	18	18	18	18	18	18	18	18	18	18	18	18	18		18
H3923	047	1	1	04	01	H3923_047_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											54.04	40	40	40				54.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	1	1	04	01	H3923_047_1	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.32	31						569.08	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	25			25			25			25			25		25
H3923	047	2	1	04	01	H3923_047_2	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	2	1	04	01	H3923_047_2	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	2	1	04	01	H3923_047_2	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.81	18	18	18				20.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	18	18	18	18	18	18	18	18	18	18	18	18	18		18
H3923	047	2	1	04	01	H3923_047_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											54.04	40	40	40				54.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	2	1	04	01	H3923_047_2	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.32	31						569.08	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	25			25			25			25			25		25
H3923	047	3	1	04	01	H3923_047_3	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	3	1	04	01	H3923_047_3	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	3	1	04	01	H3923_047_3	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.81	18	18	18				20.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	18	18	18	18	18	18	18	18	18	18	18	18	18		18
H3923	047	3	1	04	01	H3923_047_3	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											54.04	40	40	40				54.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	3	1	04	01	H3923_047_3	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.32	31						569.08	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	25			25			25			25			25		25
H3923	047	4	1	04	01	H3923_047_4	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	4	1	04	01	H3923_047_4	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	4	1	04	01	H3923_047_4	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.81	18	18	18				20.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	18	18	18	18	18	18	18	18	18	18	18	18	18		18
H3923	047	4	1	04	01	H3923_047_4	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											54.04	40	40	40				54.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	4	1	04	01	H3923_047_4	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.32	31						569.08	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	25			25			25			25			25		25
H3923	047	5	1	04	01	H3923_047_5	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	5	1	04	01	H3923_047_5	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	5	1	04	01	H3923_047_5	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.81	18	18	18				20.79	18	18	18										18	18	18				18	18	18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	18	18	18	18	18	18	18	18	18	18	18	18	18		18
H3923	047	5	1	04	01	H3923_047_5	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											54.04	40	40	40				54.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	047	5	1	04	01	H3923_047_5	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.32	31						569.08	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	25			25			25			25			25		25
H3923	048	2	1	04	01	H3923_048_2	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	2	1	04	01	H3923_048_2	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	2	1	04	01	H3923_048_2	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.73	16	16	16				20.87	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	048	2	1	04	01	H3923_048_2	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											59.64	39	39	39				60.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	2	1	04	01	H3923_048_2	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											461.99	26						455.53	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	25			25			25			25			25		25
H3923	048	3	1	04	01	H3923_048_3	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	3	1	04	01	H3923_048_3	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	3	1	04	01	H3923_048_3	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.73	16	16	16				20.87	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	048	3	1	04	01	H3923_048_3	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											59.64	39	39	39				60.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	3	1	04	01	H3923_048_3	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											461.99	26						455.53	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	25			25			25			25			25		25
H3923	048	5	1	04	01	H3923_048_5	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	5	1	04	01	H3923_048_5	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	5	1	04	01	H3923_048_5	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											20.73	16	16	16				20.87	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	16	16	16	16	16	16	16	16	16	16	16	16	16		16
H3923	048	5	1	04	01	H3923_048_5	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											59.64	39	39	39				60.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3923	048	5	1	04	01	H3923_048_5	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											461.99	26						455.53	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	25			25			25			25			25		25
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	2.00	4.00	5.00																			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																														
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				75.52	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
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				53.26	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3924	059	21	1	04	01	H3924_059_21	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, 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	2.00	4.00	5.00																			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																														
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				75.52	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
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				53.26	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3924	059	22	1	04	01	H3924_059_22	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, 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	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	2.00	4.00	5.00																			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																														
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				77.05	25	25	25																		25	25	25															25			25								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	25	25	25				25	25	25				25		25
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				50.36	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3924	065	0	1	04	01	H3924_065_0	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, 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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.76	24	24	24				88.76	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3928	001	0	1	01	01	H3928_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											38.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3928	001	0	1	01	01	H3928_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											507.70	25						612.93	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	25			25			25			25			25		25
H3931	004	0	1	02	01	H3931_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																														
H3931	004	0	1	02	01	H3931_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																														
H3931	004	0	1	02	01	H3931_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											55.14	24	24	24				78.07	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	004	0	1	02	01	H3931_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											39.41	25	25	25				50.55	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	004	0	1	02	01	H3931_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											471.80	25						593.66	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	25			25			25			25			25		25
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											69.24	24	24	24				101.02	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.01	25	25	25				44.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											568.86	25						569.00	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	25			25			25			25			25		25
H3931	092	0	1	01	01	H3931_092_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	092	0	1	01	01	H3931_092_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	092	0	1	01	01	H3931_092_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.39	24	24	24				98.90	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	092	0	1	01	01	H3931_092_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				40.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	092	0	1	01	01	H3931_092_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											547.95	25						620.51	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	25			25			25			25			25		25
H3931	094	0	1	01	01	H3931_094_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	094	0	1	01	01	H3931_094_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	094	0	1	01	01	H3931_094_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.84	24	24	24				96.50	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	094	0	1	01	01	H3931_094_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											48.67	25	25	25				45.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	094	0	1	01	01	H3931_094_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											554.25	25						650.20	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	25			25			25			25			25		25
H3931	095	0	1	02	01	H3931_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																														
H3931	095	0	1	02	01	H3931_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																														
H3931	095	0	1	02	01	H3931_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											82.13	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	095	0	1	02	01	H3931_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											44.88	25	25	25				51.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	095	0	1	02	01	H3931_095_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											583.48	25						646.05	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	25			25			25			25			25		25
H3931	099	0	1	02	01	H3931_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																														
H3931	099	0	1	02	01	H3931_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																														
H3931	099	0	1	02	01	H3931_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											68.37	24	24	24				98.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	099	0	1	02	01	H3931_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											35.97	25	25	25				41.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	099	0	1	02	01	H3931_099_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											524.65	25						591.91	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	25			25			25			25			25		25
H3931	100	0	1	02	01	H3931_100_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	100	0	1	02	01	H3931_100_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.64	24	24	24				97.87	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	100	0	1	02	01	H3931_100_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.83	25	25	25				45.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	100	0	1	02	01	H3931_100_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											562.94	25						563.92	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	25			25			25			25			25		25
H3931	101	0	1	02	01	H3931_101_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	101	0	1	02	01	H3931_101_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.91	24	24	24				93.73	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	101	0	1	02	01	H3931_101_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.93	25	25	25				42.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	101	0	1	02	01	H3931_101_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											531.33	25						606.75	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	25			25			25			25			25		25
H3931	102	0	1	01	01	H3931_102_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.52	24	24	24				94.30	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	102	0	1	01	01	H3931_102_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.57	25	25	25				43.62	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	102	0	1	01	01	H3931_102_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											546.80	25						652.32	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											62.35	22	22	22				84.44	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											41.67	25	25	25				44.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											565.03	27						657.33	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											62.87	22	22	22				85.31	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											40.20	25	25	25				44.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											553.61	27						695.27	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											63.09	22	22	22				84.82	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											39.79	25	25	25				46.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.92	27						741.80	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	25			25			25			25			25		25
H3931	126	0	1	01	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	01	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	01	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											59.16	24	24	24				91.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	126	0	1	01	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											40.32	25	25	25				49.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	126	0	1	01	01	H3931_126_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											535.04	25						778.41	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	25			25			25			25			25		25
H3931	129	0	1	01	01	H3931_129_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	129	0	1	01	01	H3931_129_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	129	0	1	01	01	H3931_129_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											60.97	24	24	24				96.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	129	0	1	01	01	H3931_129_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											44.55	25	25	25				46.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	129	0	1	01	01	H3931_129_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.42	25						638.39	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	25			25			25			25			25		25
H3931	143	0	1	02	01	H3931_143_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	143	0	1	02	01	H3931_143_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.13	24	24	24				103.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	143	0	1	02	01	H3931_143_0	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				47.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	143	0	1	02	01	H3931_143_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											549.14	25						669.33	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	25			25			25			25			25		25
H3931	146	0	1	01	01	H3931_146_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	146	0	1	01	01	H3931_146_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	146	0	1	01	01	H3931_146_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.61	24	24	24				90.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	146	0	1	01	01	H3931_146_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											40.21	25	25	25				45.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	146	0	1	01	01	H3931_146_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											498.08	25						659.77	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	25			25			25			25			25		25
H3931	151	0	1	01	01	H3931_151_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	151	0	1	01	01	H3931_151_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	151	0	1	01	01	H3931_151_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.10	25	25	25				90.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	151	0	1	01	01	H3931_151_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											50.79	26	26	26				43.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	151	0	1	01	01	H3931_151_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											686.35	29						731.50	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3931	152	0	1	01	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	01	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	01	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											67.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	152	0	1	01	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											43.04	25	25	25				48.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	152	0	1	01	01	H3931_152_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											570.49	25						614.64	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	25			25			25			25			25		25
H3931	153	0	1	02	01	H3931_153_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	153	0	1	02	01	H3931_153_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	153	0	1	02	01	H3931_153_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.59	24	24	24				90.64	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	153	0	1	02	01	H3931_153_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											41.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	153	0	1	02	01	H3931_153_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											565.37	25						689.21	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	25			25			25			25			25		25
H3931	154	0	1	02	01	H3931_154_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	154	0	1	02	01	H3931_154_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	154	0	1	02	01	H3931_154_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.06	24	24	24				92.25	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	154	0	1	02	01	H3931_154_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											36.87	25	25	25				46.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	154	0	1	02	01	H3931_154_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											635.69	25						716.00	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	25			25			25			25			25		25
H3931	157	0	1	01	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	01	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	01	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											65.91	22	22	22				86.96	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3931	157	0	1	01	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											42.73	25	25	25				48.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	157	0	1	01	01	H3931_157_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											580.86	25						693.07	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	25			25			25			25			25		25
H3931	158	0	1	02	01	H3931_158_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	158	0	1	02	01	H3931_158_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.03	22	22	22				86.67	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3931	158	0	1	02	01	H3931_158_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.27	25	25	25				46.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	158	0	1	02	01	H3931_158_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											547.92	27						685.46	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3931	160	0	1	01	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	01	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	01	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											68.30	22	22	22				86.50	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3931	160	0	1	01	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											43.02	25	25	25				47.51	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	160	0	1	01	01	H3931_160_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											565.97	25						652.77	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	25			25			25			25			25		25
H3931	162	0	1	01	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	01	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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	162	0	1	01	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											67.31	24	24	24				93.64	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	162	0	1	01	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											41.27	25	25	25				47.41	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	162	0	1	01	01	H3931_162_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											514.06	25						624.12	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	25			25			25			25			25		25
H3931	175	0	1	01	01	H3931_175_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3931	175	0	1	01	01	H3931_175_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3931	175	0	1	01	01	H3931_175_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				69.77	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	22	22	22				22	22	22				22		22
H3931	175	0	1	01	01	H3931_175_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				36.76	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3931	175	0	1	01	01	H3931_175_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				469.55	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3931	188	0	1	01	01	H3931_188_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	188	0	1	01	01	H3931_188_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	188	0	1	01	01	H3931_188_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.47	22	22	22				92.41	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3931	188	0	1	01	01	H3931_188_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				48.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	188	0	1	01	01	H3931_188_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											556.00	25						817.57	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	25			25			25			25			25		25
H3931	190	0	1	02	01	H3931_190_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	190	0	1	02	01	H3931_190_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	190	0	1	02	01	H3931_190_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	24	24	24				90.23	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	190	0	1	02	01	H3931_190_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.02	25	25	25				47.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	190	0	1	02	01	H3931_190_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.52	25						656.42	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	25			25			25			25			25		25
H3931	191	0	1	01	01	H3931_191_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	191	0	1	01	01	H3931_191_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	191	0	1	01	01	H3931_191_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.36	22	22	22				89.90	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3931	191	0	1	01	01	H3931_191_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											38.37	25	25	25				47.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	191	0	1	01	01	H3931_191_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											539.15	25						780.84	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	25			25			25			25			25		25
H3931	196	0	1	01	01	H3931_196_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3931	196	0	1	01	01	H3931_196_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3931	196	0	1	01	01	H3931_196_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				73.44	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	22	22	22				22	22	22				22		22
H3931	196	0	1	01	01	H3931_196_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				37.01	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3931	196	0	1	01	01	H3931_196_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				504.92	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3931	197	0	1	01	01	H3931_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																														
H3931	197	0	1	01	01	H3931_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																														
H3931	197	0	1	01	01	H3931_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											65.96	24	24	24				95.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3931	197	0	1	01	01	H3931_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											41.03	25	25	25				47.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3931	197	0	1	01	01	H3931_197_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											586.89	25						733.15	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	25			25			25			25			25		25
H3949	009	0	1	01	01	H3949_009_0	9		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								17.00	34.00	51.00					0.00	0.00	0.00											17.00	34.00	51.00				0.00	0.00	0.00				17.00				17.00			0.57	0.00		0.57	0.00	0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	17.00	34.00	51.00	0.00	0.00	0.00	17.00	34.00	51.00	0.00	0.00	0.00	17.00		17.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H3949	009	0	1	01	01	H3949_009_0	9		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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	009	0	1	01	01	H3949_009_0	9		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											21.00	23	23	23				21.73	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H3949	009	0	1	01	01	H3949_009_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											51.26	25	25	25				56.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	009	0	1	01	01	H3949_009_0	9		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											474.51	25						460.33	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	25			25			25			25			25		25
H3949	024	0	1	01	01	H3949_024_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, 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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H3949	024	0	1	01	01	H3949_024_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, 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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	024	0	1	01	01	H3949_024_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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	024	0	1	01	01	H3949_024_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											49.28	50	50	50				53.08	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	024	0	1	01	01	H3949_024_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											649.25	29						585.13	29												29						29					29			29								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	25			25			25			25			25		25
H3949	024	0	1	01	01	H3949_024_0	5			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	030	0	1	01	01	H3949_030_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	030	0	1	01	01	H3949_030_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											66.22	50	50	50				73.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											676.41	30						675.72	30												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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	031	0	1	01	01	H3949_031_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	031	0	1	01	01	H3949_031_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											67.15	50	50	50				67.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											680.22	29						590.75	29												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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	035	0	1	01	01	H3949_035_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	035	0	1	01	01	H3949_035_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											65.96	50	50	50				66.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											695.43	30						755.35	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	045	0	1	01	01	H3949_045_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	045	0	1	01	01	H3949_045_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											65.42	50	50	50				66.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											685.40	30						600.71	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	047	0	1	01	01	H3949_047_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	047	0	1	01	01	H3949_047_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											65.57	50	50	50				68.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											695.36	30						574.63	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	048	0	1	01	01	H3949_048_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	048	0	1	01	01	H3949_048_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											67.45	50	50	50				74.51	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											688.77	30						692.50	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	049	0	1	01	01	H3949_049_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	049	0	1	01	01	H3949_049_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											69.41	50	50	50				70.70	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											735.90	30						636.84	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	052	0	1	01	01	H3949_052_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	052	0	1	01	01	H3949_052_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											64.30	50	50	50				71.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											670.43	30						689.71	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	053	0	1	01	01	H3949_053_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	053	0	1	01	01	H3949_053_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											65.83	50	50	50				71.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											584.01	26						591.77	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	25			25			25			25			25		25
H3949	054	0	1	01	01	H3949_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								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H3949	054	0	1	01	01	H3949_054_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H3949	054	0	1	01	01	H3949_054_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	054	0	1	01	01	H3949_054_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											65.22	50	50	50				65.72	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3949	054	0	1	01	01	H3949_054_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											680.52	30						602.15	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	25			25			25			25			25		25
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	18.00					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	40.00					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											42.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											53.00	35	35	35				48.00	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	18.00					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	40.00					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											42.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											51.00	35	35	35				37.00	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	18.00					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	40.00					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											44.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											55.00	36	36	36				48.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	18.00					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	40.00					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											39.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											55.00	36	36	36				43.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H3952	053	0	1	02	01	H3952_053_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	18.00					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	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	40.00					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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											48.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	053	0	1	02	01	H3952_053_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.00	37	37	37				44.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	053	0	1	02	01	H3952_053_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	25	25	25	25	25	25	25	25	25				25		25
H3952	054	0	1	02	01	H3952_054_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	18.00					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	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	40.00					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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											47.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	054	0	1	02	01	H3952_054_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											55.00	37	37	37				50.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	054	0	1	02	01	H3952_054_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	25	25	25	25	25	25	25	25	25				25		25
H3952	055	0	1	01	01	H3952_055_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	18.00					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	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	40.00					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	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	055	0	1	01	01	H3952_055_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											56.00	42	42	42				48.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	055	0	1	01	01	H3952_055_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	25	25	25	25	25	25	25	25	25				25		25
H3952	060	0	1	02	01	H3952_060_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	16.00					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	6			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	40.00					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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											44.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	060	0	1	02	01	H3952_060_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											55.00	33	33	33				47.00	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	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H3952	060	0	1	02	01	H3952_060_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	25	25	25	25	25	25	25	25	25				25		25
H3954	097	0	1	01	01	H3954_097_0	3		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, Select Care Drugs																														
H3954	097	0	1	01	01	H3954_097_0	3		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, Select Care Drugs																														
H3954	097	0	1	01	01	H3954_097_0	3		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				81.48	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	25	25	25				25	25	25				25		25
H3954	097	0	1	01	01	H3954_097_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				53.77	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	25	25	25				25	25	25				25		25
H3954	097	0	1	01	01	H3954_097_0	3		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																														
H3954	097	0	1	01	01	H3954_097_0	3		N	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	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	2.00	4.00	5.00																			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																														
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				71.37	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
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				57.66	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	157	21	1	01	01	H3954_157_21	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, 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	2.00	4.00	5.00																			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																														
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				71.37	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
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				57.66	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	157	22	1	01	01	H3954_157_22	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, 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	3			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	5.00																			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																														
H3954	157	23	1	01	01	H3954_157_23	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	23	1	01	01	H3954_157_23	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				71.37	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	157	23	1	01	01	H3954_157_23	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				57.66	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	157	23	1	01	01	H3954_157_23	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, Select Care Drugs																														
H3954	157	23	1	01	01	H3954_157_23	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	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	2.00	4.00	5.00																			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																														
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				82.09	25	25	25																		25	25	25															25			25								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	25	25	25				25	25	25				25		25
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				57.08	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	158	13	1	01	01	H3954_158_13	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, 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	3			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	5.00																			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																														
H3954	158	14	1	01	01	H3954_158_14	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	14	1	01	01	H3954_158_14	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				82.09	25	25	25																		25	25	25															25			25								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	25	25	25				25	25	25				25		25
H3954	158	14	1	01	01	H3954_158_14	3			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				57.08	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	158	14	1	01	01	H3954_158_14	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, Select Care Drugs																														
H3954	158	14	1	01	01	H3954_158_14	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	160	0	1	01	01	H3954_160_0	3			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	5.00																			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																														
H3954	160	0	1	01	01	H3954_160_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	160	0	1	01	01	H3954_160_0	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				86.43	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	160	0	1	01	01	H3954_160_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				63.74	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	160	0	1	01	01	H3954_160_0	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, Select Care Drugs																														
H3954	160	0	1	01	01	H3954_160_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	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	2.00	4.00	5.00																			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																														
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				78.93	25	25	25																		25	25	25															25			25								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	25	25	25				25	25	25				25		25
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				53.05	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	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H3954	161	0	1	01	01	H3954_161_0	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, 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	3			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	3			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	3			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				79.99	25	25	25																		25	25	25															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	25	25	25				25	25	25				25		25
H3954	163	0	1	01	01	H3954_163_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				68.64	50	50	50																		50	50	50															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	25	25	25				25	25	25				25		25
H3954	163	0	1	01	01	H3954_163_0	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, Select Care Drugs																														
H3954	163	0	1	01	01	H3954_163_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																														
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	20		20	20		20			20			20	20		20
H3957	031	0	1	02	01	H3957_031_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											89.54	35		35				89.54	35		35												35						35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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	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											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	2	1	01	01	H3957_042_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	2	1	01	01	H3957_042_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	2	1	01	01	H3957_042_2	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	042	2	1	01	01	H3957_042_2	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
H3957	042	2	1	01	01	H3957_042_2	7			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																														
H3957	042	4	1	01	01	H3957_042_4	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	4	1	01	01	H3957_042_4	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	4	1	01	01	H3957_042_4	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	042	4	1	01	01	H3957_042_4	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
H3957	042	4	1	01	01	H3957_042_4	7			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																														
H3957	042	5	1	01	01	H3957_042_5	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	5	1	01	01	H3957_042_5	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	5	1	01	01	H3957_042_5	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	042	5	1	01	01	H3957_042_5	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
H3957	042	5	1	01	01	H3957_042_5	7			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																														
H3957	042	6	1	01	01	H3957_042_6	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	6	1	01	01	H3957_042_6	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	042	6	1	01	01	H3957_042_6	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	042	6	1	01	01	H3957_042_6	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
H3957	042	6	1	01	01	H3957_042_6	7			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																														
H3957	042	7	1	01	01	H3957_042_7	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	7	1	01	01	H3957_042_7	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	7	1	01	01	H3957_042_7	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											69.70	20		20				69.70	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	042	7	1	01	01	H3957_042_7	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											66.22	25		25				66.22	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	20		20	20		20			20			20	20		20
H3957	042	7	1	01	01	H3957_042_7	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																														
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	20		20	20		20			20			20	20		20
H3957	044	1	1	02	01	H3957_044_1	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											88.65	35		35				88.65	35		35												35						35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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	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	044	4	1	02	01	H3957_044_4	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	044	4	1	02	01	H3957_044_4	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	20		20	20		20			20			20	20		20
H3957	044	4	1	02	01	H3957_044_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											88.65	35		35				88.65	35		35												35						35			35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	044	4	1	02	01	H3957_044_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	045	1	1	02	01	H3957_045_1	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	045	1	1	02	01	H3957_045_1	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	045	1	1	02	01	H3957_045_1	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	44.00		132.00																					110.00																44.00				44.00		1.42						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H3957	045	1	1	02	01	H3957_045_1	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H3957	045	1	1	02	01	H3957_045_1	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	045	2	1	02	01	H3957_045_2	8			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	045	2	1	02	01	H3957_045_2	8			Generic	4	01	1	2	2	1	110		01	100		1	31		100				1	2			100				31		31	13.00		39.00																					32.50																13.00				13.00		0.42						0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	045	2	1	02	01	H3957_045_2	8			Preferred Brand	4	11	1	2	3	1	110		01	100		1	31		90				1	2			90				31		31	44.00		132.00																					110.00																44.00				44.00		1.42						1.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H3957	045	2	1	02	01	H3957_045_2	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		90				1	2			90				31		31	100.00		300.00																					250.00																100.00				100.00		3.23						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H3957	045	2	1	02	01	H3957_045_2	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31					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	20		20						20				20		20
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	20		20						20				20		20
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	20		20						20				20		20
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	20		20						20				20		20
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											78.68	23		23				78.68	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											72.72	25		25				72.72	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								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											78.68	23		23				78.68	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											72.72	25		25				72.72	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								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											78.68	23		23				78.68	23		23												23						23			23			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	20		20	20		20			20			20	20		20
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											72.72	25		25				72.72	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	047	4	1	01	01	H3957_047_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	047	4	1	01	01	H3957_047_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	047	4	1	01	01	H3957_047_4	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											78.68	23		23				78.68	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	047	4	1	01	01	H3957_047_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.72	25		25				72.72	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	20		20	20		20			20			20	20		20
H3957	047	4	1	01	01	H3957_047_4	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																														
H3957	047	5	1	01	01	H3957_047_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	047	5	1	01	01	H3957_047_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	047	5	1	01	01	H3957_047_5	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											78.68	23		23				78.68	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	047	5	1	01	01	H3957_047_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.72	25		25				72.72	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	20		20	20		20			20			20	20		20
H3957	047	5	1	01	01	H3957_047_5	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																														
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											72.41	20		20				72.41	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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											72.76	25		25				72.76	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	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	049	1	1	01	01	H3957_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																														
H3957	049	1	1	01	01	H3957_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																														
H3957	049	1	1	01	01	H3957_049_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	1	1	01	01	H3957_049_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	1	1	01	01	H3957_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																														
H3957	049	2	1	01	01	H3957_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																														
H3957	049	2	1	01	01	H3957_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																														
H3957	049	2	1	01	01	H3957_049_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	2	1	01	01	H3957_049_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	2	1	01	01	H3957_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																														
H3957	049	3	1	01	01	H3957_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																														
H3957	049	3	1	01	01	H3957_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																														
H3957	049	3	1	01	01	H3957_049_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	3	1	01	01	H3957_049_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	3	1	01	01	H3957_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																														
H3957	049	4	1	01	01	H3957_049_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	049	4	1	01	01	H3957_049_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	049	4	1	01	01	H3957_049_4	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	4	1	01	01	H3957_049_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	4	1	01	01	H3957_049_4	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																														
H3957	049	5	1	01	01	H3957_049_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	049	5	1	01	01	H3957_049_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	049	5	1	01	01	H3957_049_5	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	5	1	01	01	H3957_049_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	5	1	01	01	H3957_049_5	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																														
H3957	049	6	1	01	01	H3957_049_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	049	6	1	01	01	H3957_049_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	049	6	1	01	01	H3957_049_6	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	6	1	01	01	H3957_049_6	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	6	1	01	01	H3957_049_6	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																														
H3957	049	7	1	01	01	H3957_049_7	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	049	7	1	01	01	H3957_049_7	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	049	7	1	01	01	H3957_049_7	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											68.43	20		20				68.43	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	049	7	1	01	01	H3957_049_7	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											72.24	25		25				72.24	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	20		20	20		20			20			20	20		20
H3957	049	7	1	01	01	H3957_049_7	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																														
H3957	050	1	1	01	01	H3957_050_1	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	1	1	01	01	H3957_050_1	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	1	1	01	01	H3957_050_1	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											76.66	23		23				76.66	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	050	1	1	01	01	H3957_050_1	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.27	25		25				65.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	050	1	1	01	01	H3957_050_1	7			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																														
H3957	050	2	1	01	01	H3957_050_2	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	2	1	01	01	H3957_050_2	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	2	1	01	01	H3957_050_2	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											76.66	23		23				76.66	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	050	2	1	01	01	H3957_050_2	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.27	25		25				65.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	050	2	1	01	01	H3957_050_2	7			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																														
H3957	050	3	1	01	01	H3957_050_3	7			Preferred Generic	4	01	1	2	1	1		110	01		100	1				31		100	1	2						100	31		31								7.00		21.00					0.00		0.00													21.00						0.00				7.00				7.00			0.23	0.00				0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	3	1	01	01	H3957_050_3	7			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					0.00		0.00													45.00						0.00				15.00				15.00			0.48	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3957	050	3	1	01	01	H3957_050_3	7			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											76.66	23		23				76.66	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	050	3	1	01	01	H3957_050_3	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.27	25		25				65.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	050	3	1	01	01	H3957_050_3	7			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																														
H3957	050	4	1	01	01	H3957_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																														
H3957	050	4	1	01	01	H3957_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																														
H3957	050	4	1	01	01	H3957_050_4	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											76.66	23		23				76.66	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	050	4	1	01	01	H3957_050_4	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.27	25		25				65.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	050	4	1	01	01	H3957_050_4	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																														
H3957	050	5	1	01	01	H3957_050_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	050	5	1	01	01	H3957_050_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	050	5	1	01	01	H3957_050_5	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											76.66	23		23				76.66	23		23												23						23			23			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	20		20	20		20			20			20	20		20
H3957	050	5	1	01	01	H3957_050_5	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											65.27	25		25				65.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H3957	050	5	1	01	01	H3957_050_5	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																														
H3959	001	0	1	02	01	H3959_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																														
H3959	001	0	1	02	01	H3959_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																														
H3959	001	0	1	02	01	H3959_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											60.91	24	24	24				93.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3959	001	0	1	02	01	H3959_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											37.96	25	25	25				45.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	001	0	1	02	01	H3959_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											491.56	25						499.61	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	25			25			25			25			25		25
H3959	002	0	1	02	01	H3959_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																														
H3959	002	0	1	02	01	H3959_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																														
H3959	002	0	1	02	01	H3959_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											69.62	24	24	24				94.03	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3959	002	0	1	02	01	H3959_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											38.26	25	25	25				44.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	002	0	1	02	01	H3959_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											508.52	25						547.20	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											61.31	22	22	22				88.39	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											37.88	25	25	25				45.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											571.71	27						575.97	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	25			25			25			25			25		25
H3959	011	0	1	02	01	H3959_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																														
H3959	011	0	1	02	01	H3959_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																														
H3959	011	0	1	02	01	H3959_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											63.48	22	22	22				88.27	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3959	011	0	1	02	01	H3959_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											37.10	25	25	25				45.93	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	011	0	1	02	01	H3959_011_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											531.54	27						552.97	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	25			25			25			25			25		25
H3959	032	0	1	02	01	H3959_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																														
H3959	032	0	1	02	01	H3959_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																														
H3959	032	0	1	02	01	H3959_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											68.85	24	24	24				95.24	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3959	032	0	1	02	01	H3959_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											37.69	25	25	25				46.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	032	0	1	02	01	H3959_032_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											531.72	25						582.56	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3959	033	0	1	02	01	H3959_033_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.04	22	22	22				89.49	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3959	033	0	1	02	01	H3959_033_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.37	25	25	25				48.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	033	0	1	02	01	H3959_033_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											568.45	25						636.95	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	25			25			25			25			25		25
H3959	035	0	1	01	01	H3959_035_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	035	0	1	01	01	H3959_035_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	035	0	1	01	01	H3959_035_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				74.76	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	22	22	22				22	22	22				22		22
H3959	035	0	1	01	01	H3959_035_0	2		N	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	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	035	0	1	01	01	H3959_035_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				519.19	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	036	0	1	01	01	H3959_036_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	036	0	1	01	01	H3959_036_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	036	0	1	01	01	H3959_036_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				71.11	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	22	22	22				22	22	22				22		22
H3959	036	0	1	01	01	H3959_036_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.47	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	036	0	1	01	01	H3959_036_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				475.77	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											69.18	24	24	24				97.90	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.51	25	25	25				47.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											543.17	25						560.33	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	25			25			25			25			25		25
H3959	039	0	1	02	01	H3959_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																														
H3959	039	0	1	02	01	H3959_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																														
H3959	039	0	1	02	01	H3959_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											65.10	24	24	24				92.26	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3959	039	0	1	02	01	H3959_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											33.79	25	25	25				45.94	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	039	0	1	02	01	H3959_039_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.37	25						594.07	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	25			25			25			25			25		25
H3959	052	0	1	02	01	H3959_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																														
H3959	052	0	1	02	01	H3959_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																														
H3959	052	0	1	02	01	H3959_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											69.66	24	24	24				94.74	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H3959	052	0	1	02	01	H3959_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											43.91	25	25	25				46.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	052	0	1	02	01	H3959_052_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											570.15	25						574.72	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	25			25			25			25			25		25
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											77.28	24	24	24				100.50	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.76	25	25	25				47.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											569.40	25						602.12	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											72.99	24	24	24				94.89	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.27	25	25	25				42.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											557.95	25						616.02	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	25			25			25			25			25		25
H3959	069	0	1	01	01	H3959_069_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	069	0	1	01	01	H3959_069_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	069	0	1	01	01	H3959_069_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				70.85	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	22	22	22				22	22	22				22		22
H3959	069	0	1	01	01	H3959_069_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				36.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	069	0	1	01	01	H3959_069_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				478.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	070	0	1	01	01	H3959_070_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	070	0	1	01	01	H3959_070_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	070	0	1	01	01	H3959_070_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				70.85	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	22	22	22				22	22	22				22		22
H3959	070	0	1	01	01	H3959_070_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				36.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	070	0	1	01	01	H3959_070_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				478.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	071	0	1	01	01	H3959_071_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	071	0	1	01	01	H3959_071_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	071	0	1	01	01	H3959_071_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				70.85	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	22	22	22				22	22	22				22		22
H3959	071	0	1	01	01	H3959_071_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				36.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	071	0	1	01	01	H3959_071_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				478.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	072	0	1	01	01	H3959_072_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	072	0	1	01	01	H3959_072_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	072	0	1	01	01	H3959_072_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				70.85	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	22	22	22				22	22	22				22		22
H3959	072	0	1	01	01	H3959_072_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				36.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	072	0	1	01	01	H3959_072_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				478.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	073	0	1	01	01	H3959_073_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	073	0	1	01	01	H3959_073_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	073	0	1	01	01	H3959_073_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				70.85	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	22	22	22				22	22	22				22		22
H3959	073	0	1	01	01	H3959_073_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				36.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	073	0	1	01	01	H3959_073_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				478.38	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	074	0	1	01	01	H3959_074_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	074	0	1	01	01	H3959_074_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3959	074	0	1	01	01	H3959_074_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				77.23	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	074	0	1	01	01	H3959_074_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				38.74	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	074	0	1	01	01	H3959_074_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				504.05	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	075	0	1	01	01	H3959_075_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	075	0	1	01	01	H3959_075_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3959	075	0	1	01	01	H3959_075_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				91.68	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	075	0	1	01	01	H3959_075_0	2			Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				43.79	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	25	25	25				25	25	25				25		25
H3959	075	0	1	01	01	H3959_075_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				571.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.65	22	22	22				90.15	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											36.99	25	25	25				46.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											504.26	25						805.57	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	25			25			25			25			25		25
H3959	083	0	1	01	01	H3959_083_0	2			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	083	0	1	01	01	H3959_083_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3959	083	0	1	01	01	H3959_083_0	2			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				98.16	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	083	0	1	01	01	H3959_083_0	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	083	0	1	01	01	H3959_083_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				564.69	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3959	084	0	1	01	01	H3959_084_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	084	0	1	01	01	H3959_084_0	2			Generic	4	01	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	084	0	1	01	01	H3959_084_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.83	22	22	22				95.96	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H3959	084	0	1	01	01	H3959_084_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.34	25	25	25				49.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3959	084	0	1	01	01	H3959_084_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											564.94	25						840.34	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	25			25			25			25			25		25
H3959	085	0	1	01	01	H3959_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H3959	085	0	1	01	01	H3959_085_0	2			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	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																														
H3959	085	0	1	01	01	H3959_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				93.63	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	085	0	1	01	01	H3959_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				44.41	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H3959	085	0	1	01	01	H3959_085_0	2			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				586.28	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H3962	001	0	1	01	01	H3962_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	001	0	1	01	01	H3962_001_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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	001	0	1	01	01	H3962_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	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	001	0	1	01	01	H3962_001_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	001	0	1	01	01	H3962_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.62	31						700.47	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	25			25			25			25			25		25
H3962	004	0	1	01	01	H3962_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	004	0	1	01	01	H3962_004_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											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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	004	0	1	01	01	H3962_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					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	004	0	1	01	01	H3962_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											88.70	37	37	37				99.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	004	0	1	01	01	H3962_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											697.50	31						697.65	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	25			25			25			25			25		25
H3962	022	1	1	01	01	H3962_022_1	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	1	1	01	01	H3962_022_1	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	1	1	01	01	H3962_022_1	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.66	19	19	19				25.48	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3962	022	1	1	01	01	H3962_022_1	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											66.10	40	40	40				60.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	1	1	01	01	H3962_022_1	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.67	28						513.27	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3962	022	2	1	01	01	H3962_022_2	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	2	1	01	01	H3962_022_2	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	2	1	01	01	H3962_022_2	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.66	19	19	19				25.48	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3962	022	2	1	01	01	H3962_022_2	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											66.10	40	40	40				60.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	2	1	01	01	H3962_022_2	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.67	28						513.27	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3962	022	3	1	01	01	H3962_022_3	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	3	1	01	01	H3962_022_3	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	3	1	01	01	H3962_022_3	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.66	19	19	19				25.48	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3962	022	3	1	01	01	H3962_022_3	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											66.10	40	40	40				60.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	3	1	01	01	H3962_022_3	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.67	28						513.27	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3962	022	4	1	01	01	H3962_022_4	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	4	1	01	01	H3962_022_4	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	4	1	01	01	H3962_022_4	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.66	19	19	19				25.48	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3962	022	4	1	01	01	H3962_022_4	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											66.10	40	40	40				60.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	4	1	01	01	H3962_022_4	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.67	28						513.27	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3962	022	5	1	01	01	H3962_022_5	3			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	5	1	01	01	H3962_022_5	3			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	45.00					0.00	0.00	0.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	5	1	01	01	H3962_022_5	3			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.66	19	19	19				25.48	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	19	19	19	19	19	19	19	19	19	19	19	19	19		19
H3962	022	5	1	01	01	H3962_022_5	3			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											66.10	40	40	40				60.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3962	022	5	1	01	01	H3962_022_5	3			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											598.67	28						513.27	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H3975	001	0	1	04	01	H3975_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H3975	001	0	1	04	01	H3975_001_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H3975	001	0	1	04	01	H3975_001_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											121.85	25	25	25				121.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3975	001	0	1	04	01	H3975_001_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											58.28	34	34	34				58.28	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3975	001	0	1	04	01	H3975_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3975	001	0	1	04	01	H3975_001_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3975	004	0	1	04	01	H3975_004_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3975	004	0	1	04	01	H3975_004_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3975	004	0	1	04	01	H3975_004_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											103.69	25	25	25				103.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3975	004	0	1	04	01	H3975_004_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H3975	004	0	1	04	01	H3975_004_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H3975	004	0	1	04	01	H3975_004_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3979	001	0	1	01	01	H3979_001_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3979	001	0	1	01	01	H3979_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											54.62	19	19	19				48.86	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H3979	001	0	1	01	01	H3979_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											67.42	40	40	40				73.00	38	38	38										40	40	40				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H3979	001	0	1	01	01	H3979_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											610.99	27						711.28	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4003	009	0	1	01	01	H4003_009_0	5			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	009	0	1	01	01	H4003_009_0	5			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	009	0	1	01	01	H4003_009_0	5			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	009	0	1	01	01	H4003_009_0	5			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	10.00		20.00						20.00				10.00		10.00	25		25						25				25		25
H4003	009	0	1	01	01	H4003_009_0	5			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				447.51	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	009	0	1	01	01	H4003_009_0	5			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				511.91	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	009	0	1	01	01	H4003_009_0	5			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4003	019	0	1	02	01	H4003_019_0	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	019	0	1	02	01	H4003_019_0	6			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	019	0	1	02	01	H4003_019_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	3.00		6.00																					6.00																3.00				3.00		0.10						0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	019	0	1	02	01	H4003_019_0	6			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	5.00		10.00						10.00				5.00		5.00	25		25						25				25		25
H4003	019	0	1	02	01	H4003_019_0	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				586.48	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	019	0	1	02	01	H4003_019_0	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				302.01	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	019	0	1	02	01	H4003_019_0	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4003	034	0	1	02	01	H4003_034_0	5			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	034	0	1	02	01	H4003_034_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	034	0	1	02	01	H4003_034_0	5			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	034	0	1	02	01	H4003_034_0	5			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4003	034	0	1	02	01	H4003_034_0	5			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				913.33	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	034	0	1	02	01	H4003_034_0	5			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				329.62	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	034	0	1	02	01	H4003_034_0	5			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	055	0	1	02	01	H4003_055_0	6			Generic	4	01	1	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4003	055	0	1	02	01	H4003_055_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	12.00		24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	12.00		24.00						24.00				12.00		12.00	25		25						25				25		25
H4003	055	0	1	02	01	H4003_055_0	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				643.27	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	055	0	1	02	01	H4003_055_0	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				265.78	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4003	055	0	1	02	01	H4003_055_0	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	056	0	1	02	01	H4004_056_0	7			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	056	0	1	02	01	H4004_056_0	7			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	056	0	1	02	01	H4004_056_0	7			Preferred Brand	4	10	1	2	3	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	056	0	1	02	01	H4004_056_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H4004	056	0	1	02	01	H4004_056_0	7			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				651.66	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	056	0	1	02	01	H4004_056_0	7			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				247.70	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	056	0	1	02	01	H4004_056_0	7			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	065	0	1	02	01	H4004_065_0	5			Generic	4	01	3	2	2	1	110		01	100		1	30		90				2	1			90				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	065	0	1	02	01	H4004_065_0	5			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	7.00		14.00						14.00				7.00		7.00	25		25						25				25		25
H4004	065	0	1	02	01	H4004_065_0	5			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				738.24	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	065	0	1	02	01	H4004_065_0	5			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				269.05	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	065	0	1	02	01	H4004_065_0	5			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	066	0	1	02	01	H4004_066_0	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	066	0	1	02	01	H4004_066_0	6			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	066	0	1	02	01	H4004_066_0	6			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	066	0	1	02	01	H4004_066_0	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	18.00		36.00																					36.00																18.00				18.00		0.60						0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	18.00		36.00						36.00				18.00		18.00	25		25						25				25		25
H4004	066	0	1	02	01	H4004_066_0	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				584.01	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	066	0	1	02	01	H4004_066_0	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				356.17	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	066	0	1	02	01	H4004_066_0	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	070	0	1	02	01	H4004_070_0	5			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	070	0	1	02	01	H4004_070_0	5			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	070	0	1	02	01	H4004_070_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	5.00		10.00																					10.00																5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	070	0	1	02	01	H4004_070_0	5			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	15.00		30.00						30.00				15.00		15.00	25		25						25				25		25
H4004	070	0	1	02	01	H4004_070_0	5			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				738.09	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	070	0	1	02	01	H4004_070_0	5			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				269.02	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	070	0	1	02	01	H4004_070_0	5			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	071	0	1	02	01	H4004_071_0	5			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	071	0	1	02	01	H4004_071_0	5			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	071	0	1	02	01	H4004_071_0	5			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		90				2	1			90				30		31	10.00		20.00																					20.00																10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	071	0	1	02	01	H4004_071_0	5			Non-Preferred Drug	4	11	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	15.00		30.00						30.00				15.00		15.00	25		25						25				25		25
H4004	071	0	1	02	01	H4004_071_0	5			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				738.20	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	071	0	1	02	01	H4004_071_0	5			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				269.03	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	071	0	1	02	01	H4004_071_0	5			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	073	1	1	02	01	H4004_073_1	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	1	1	02	01	H4004_073_1	6			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	1	1	02	01	H4004_073_1	6			Preferred Brand	4	10	1	2	3	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	1	1	02	01	H4004_073_1	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H4004	073	1	1	02	01	H4004_073_1	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				412.78	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	1	1	02	01	H4004_073_1	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				263.04	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	1	1	02	01	H4004_073_1	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	073	2	1	02	01	H4004_073_2	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	2	1	02	01	H4004_073_2	6			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	2	1	02	01	H4004_073_2	6			Preferred Brand	4	10	1	2	3	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	2	1	02	01	H4004_073_2	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H4004	073	2	1	02	01	H4004_073_2	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				412.78	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	2	1	02	01	H4004_073_2	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				263.04	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	2	1	02	01	H4004_073_2	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4004	073	3	1	02	01	H4004_073_3	6			Preferred Generic	4	01	1	2	1	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	3	1	02	01	H4004_073_3	6			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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	3	1	02	01	H4004_073_3	6			Preferred Brand	4	10	1	2	3	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4004	073	3	1	02	01	H4004_073_3	6			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		90				2	1			90				30		31	8.00		16.00																					16.00																8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H4004	073	3	1	02	01	H4004_073_3	6			Preferred Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				412.78	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	3	1	02	01	H4004_073_3	6			Specialty Tier	4	11	1	1	6	1	010		01	000		1	30														30		31				263.04	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4004	073	3	1	02	01	H4004_073_3	6			Select Care Drugs	4	10	1	2	7	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 Drug, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	25		25						25				25		25
H4005	004	0	1	04	01	H4005_004_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H4005	004	0	1	04	01	H4005_004_0	5			Generic	4	01	3	2	2	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	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								45.00		90.00					30.00		60.00							60.00																45.00				30.00			1.50	1.00				0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H4005	004	0	1	04	01	H4005_004_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								75.00		150.00					50.00		100.00							100.00																75.00				50.00			2.50	1.67				1.61	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	25		25	25		25			25				25		25
H4005	004	0	1	04	01	H4005_004_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H4005	004	0	1	04	01	H4005_004_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	3.00		6.00	0.00		0.00			0.00				3.00		0.00	25		25	25		25			25				25		25
H4026	001	0	1	01	01	H4026_001_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4026	001	0	1	01	01	H4026_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4026	001	0	1	01	01	H4026_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								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4026	001	0	1	01	01	H4026_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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4026	001	0	1	01	01	H4026_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4026	002	0	1	01	01	H4026_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4026	002	0	1	01	01	H4026_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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4026	002	0	1	01	01	H4026_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								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4026	002	0	1	01	01	H4026_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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4026	002	0	1	01	01	H4026_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4032	001	0	1	02	01	H4032_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4032	001	0	1	02	01	H4032_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4032	001	0	1	02	01	H4032_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H4032	001	0	1	02	01	H4032_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4032	001	0	1	02	01	H4032_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4032	002	0	1	02	01	H4032_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4032	002	0	1	02	01	H4032_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4032	002	0	1	02	01	H4032_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H4032	002	0	1	02	01	H4032_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4032	002	0	1	02	01	H4032_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				391.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4036	008	0	1	04	01	H4036_008_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																														
H4036	008	0	1	04	01	H4036_008_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	008	0	1	04	01	H4036_008_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.00	25	25	25				78.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4036	008	0	1	04	01	H4036_008_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											30.00	30	30	30				25.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	008	0	1	04	01	H4036_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	008	0	1	04	01	H4036_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5			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	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											46.00	25	25	25				58.00	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	25	25	25	20	20	20	20	20	20				25		25
H4036	017	0	1	04	01	H4036_017_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											34.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	017	0	1	04	01	H4036_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	017	0	1	04	01	H4036_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								8.00	16.00	24.00					3.00	6.00	9.00					0.00	0.00	0.00																8.00				8.00			0.27	0.10	0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	025	0	1	04	01	H4036_025_0	5			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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.00	25	25	25				57.00	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	25	25	25	20	20	20	20	20	20				25		25
H4036	025	0	1	04	01	H4036_025_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											30.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	025	0	1	04	01	H4036_025_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	025	0	1	04	01	H4036_025_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																														
H4036	026	0	1	04	01	H4036_026_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																														
H4036	026	0	1	04	01	H4036_026_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.00	28.00	42.00					9.00	18.00	27.00					0.00	0.00	0.00																14.00				14.00			0.47	0.30	0.00			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	026	0	1	04	01	H4036_026_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											51.00	25	25	25				62.00	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	25	25	25	20	20	20	20	20	20				25		25
H4036	026	0	1	04	01	H4036_026_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											28.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	026	0	1	04	01	H4036_026_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	026	0	1	04	01	H4036_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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								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			0.29	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											53.00	25	25	25				77.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
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											28.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
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												30							30						30																	30			30								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	034	0	1	04	01	H4036_034_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																														
H4036	034	0	1	04	01	H4036_034_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																														
H4036	034	0	1	04	01	H4036_034_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											42.00	20	20	20				58.00	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	20	20	20	20	20	20	20	20	20				20		20
H4036	034	0	1	04	01	H4036_034_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											28.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	034	0	1	04	01	H4036_034_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	034	0	1	04	01	H4036_034_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																														
H4036	036	0	1	04	01	H4036_036_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																														
H4036	036	0	1	04	01	H4036_036_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	036	0	1	04	01	H4036_036_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											51.00	25	25	25				73.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4036	036	0	1	04	01	H4036_036_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											25.00	30	30	30				23.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4036	036	0	1	04	01	H4036_036_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4036	036	0	1	04	01	H4036_036_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																														
H4045	001	0	1	01	01	H4045_001_0	3		N	Generic	4	01	1	1	1	1	111		10	100		1	31	60	100				2	2			100					30	31				5.05	25	25	25																				25																25		25								Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H4045	001	0	1	01	01	H4045_001_0	3		N	Preferred Brand	4	10	1	1	2	1	111		10	100		1	31	60	100				2	2			100					30	31				78.56	25	25	25																				25																25		25								Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H4045	001	0	1	01	01	H4045_001_0	3		N	Non-Preferred Brand	4	10	1	1	3	1	111		10	100		1	31	60	100				2	2			100					30	31				59.41	25	25	25																				25																25		25								Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H4045	001	0	1	01	01	H4045_001_0	3		N	Preferred Specialty Tier	4	11	1	1	4	1	111		10	100		1	31	60	100				2	2			100					30	31				635.48	25	25	25																				25																25		25								Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4045	001	0	1	01	01	H4045_001_0	3		N	Specialty Tier	4	11	1	1	5	1	111		10	100		1	31	60	100				2	2			100					30	31				301.32	25	25	25																				25																25		25								Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4045	001	0	1	01	01	H4045_001_0	3		N	Select Care Drugs	4	01	1	2	6	1	111		10	100		1	31	60	100				1	2			100					30	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Generic, Preferred Brand, Non-Preferred Brand, Preferred Specialty Tier, Specialty Tier, Select Care Drugs																														
H4057	001	0	1	01	01	H4057_001_0	4		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		34	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H4057	001	0	1	01	01	H4057_001_0	4		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	90				2	2			90				30		34				11.01	25	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	25	25	25						25				25		25
H4057	001	0	1	01	01	H4057_001_0	4		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		34				86.70	25	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	25	25	25						25				25		25
H4057	001	0	1	01	01	H4057_001_0	4		N	Non-Preferred Drug	4	11	3	1	4	1	111		01	100		1	30	60	90				2	2			90				30		34				50.16	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H4057	001	0	1	01	01	H4057_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		34				434.05	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H4057	001	0	1	01	01	H4057_001_0	4		N	Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	100				2	2			100				30		34	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H4073	001	0	1	02	01	H4073_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4073	001	0	1	02	01	H4073_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4073	001	0	1	02	01	H4073_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.50	25	25	25				123.50	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	001	0	1	02	01	H4073_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.03	35	35	35				75.80	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	001	0	1	02	01	H4073_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	001	0	1	02	01	H4073_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	002	0	1	02	01	H4073_002_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	002	0	1	02	01	H4073_002_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	002	0	1	02	01	H4073_002_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											111.03	25	25	25				111.03	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	002	0	1	02	01	H4073_002_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	002	0	1	02	01	H4073_002_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	002	0	1	02	01	H4073_002_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	003	0	1	02	01	H4073_003_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	003	0	1	02	01	H4073_003_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	003	0	1	02	01	H4073_003_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.94	25	25	25				100.94	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	003	0	1	02	01	H4073_003_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	003	0	1	02	01	H4073_003_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	003	0	1	02	01	H4073_003_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	004	0	1	02	01	H4073_004_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	004	0	1	02	01	H4073_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	004	0	1	02	01	H4073_004_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.10	25	25	25				97.10	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	004	0	1	02	01	H4073_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4073	004	0	1	02	01	H4073_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4073	004	0	1	02	01	H4073_004_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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 Drug, 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 Drug, 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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4091	003	0	1	04	01	H4091_003_0	4			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				750.13	31	31	31																		31	31	31																31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				569.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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	8		N	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	002	0	1	01	01	H4140_002_0	8		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, Supplemental Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4140	002	0	1	01	01	H4140_002_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				115.06	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	25	25	25				25	25	25				25		25
H4140	002	0	1	01	01	H4140_002_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				55.81	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	25	25	25				25	25	25				25		25
H4140	002	0	1	01	01	H4140_002_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				607.63	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	002	0	1	01	01	H4140_002_0	8		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	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	004	0	1	01	01	H4140_004_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	0	0	0				0	0	0				0		0
H4140	004	0	1	01	01	H4140_004_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	0	0	0				0	0	0				0		0
H4140	004	0	1	01	01	H4140_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	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	25	25	25				25	25	25				25		25
H4140	004	0	1	01	01	H4140_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				958.76	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	004	0	1	01	01	H4140_004_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	012	0	1	01	01	H4140_012_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	012	0	1	01	01	H4140_012_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	0	0	0				0	0	0				0		0
H4140	012	0	1	01	01	H4140_012_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	0	0	0				0	0	0				0		0
H4140	012	0	1	01	01	H4140_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	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	25	25	25				25	25	25				25		25
H4140	012	0	1	01	01	H4140_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				740.80	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	012	0	1	01	01	H4140_012_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	013	0	1	01	01	H4140_013_0	8		N	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	013	0	1	01	01	H4140_013_0	8		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, Supplemental Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4140	013	0	1	01	01	H4140_013_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				111.98	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	25	25	25				25	25	25				25		25
H4140	013	0	1	01	01	H4140_013_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				47.63	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	25	25	25				25	25	25				25		25
H4140	013	0	1	01	01	H4140_013_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				620.84	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	013	0	1	01	01	H4140_013_0	8		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	016	0	1	01	01	H4140_016_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	016	0	1	01	01	H4140_016_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	0	0	0				0	0	0				0		0
H4140	016	0	1	01	01	H4140_016_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	0	0	0				0	0	0				0		0
H4140	016	0	1	01	01	H4140_016_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	25	25	25				25	25	25				25		25
H4140	016	0	1	01	01	H4140_016_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				652.81	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	016	0	1	01	01	H4140_016_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	017	0	1	01	01	H4140_017_0	8		N	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	017	0	1	01	01	H4140_017_0	8		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, Supplemental Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4140	017	0	1	01	01	H4140_017_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				112.77	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	25	25	25				25	25	25				25		25
H4140	017	0	1	01	01	H4140_017_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				56.35	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	25	25	25				25	25	25				25		25
H4140	017	0	1	01	01	H4140_017_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				597.89	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	017	0	1	01	01	H4140_017_0	8		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	018	0	1	01	01	H4140_018_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	018	0	1	01	01	H4140_018_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	0	0	0				0	0	0				0		0
H4140	018	0	1	01	01	H4140_018_0	8			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	25	25	25				25	25	25				25		25
H4140	018	0	1	01	01	H4140_018_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	60.00	120.00	180.00																			60.00	120.00	180.00																60.00				60.00		2.00			2.00			1.94	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	25	25	25				25	25	25				25		25
H4140	018	0	1	01	01	H4140_018_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				973.22	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	018	0	1	01	01	H4140_018_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	019	0	1	01	01	H4140_019_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	019	0	1	01	01	H4140_019_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	0	0	0				0	0	0				0		0
H4140	019	0	1	01	01	H4140_019_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	25	25	25				25	25	25				25		25
H4140	019	0	1	01	01	H4140_019_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	25	25	25				25	25	25				25		25
H4140	019	0	1	01	01	H4140_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				597.31	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4140	019	0	1	01	01	H4140_019_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	003	0	1	01	01	H4141_003_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	0		0				25		25	0		0	0		0
H4141	003	0	1	01	01	H4141_003_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	0		0				25		25	0		0	0		0
H4141	003	0	1	01	01	H4141_003_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4141	003	0	1	01	01	H4141_003_0	6		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4141	003	0	1	01	01	H4141_003_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	25						25			25			25		25
H4141	015	0	1	01	01	H4141_015_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	0		0				25		25	0		0	0		0
H4141	015	0	1	01	01	H4141_015_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4141	015	0	1	01	01	H4141_015_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	25		25				25		25	25		25	25		25
H4141	015	0	1	01	01	H4141_015_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	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	25		25				25		25	25		25	25		25
H4141	015	0	1	01	01	H4141_015_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	25						25			25			25		25
H4141	017	3	1	01	01	H4141_017_3	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	0		0				25		25	0		0	0		0
H4141	017	3	1	01	01	H4141_017_3	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4141	017	3	1	01	01	H4141_017_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	25		25				25		25	25		25	25		25
H4141	017	3	1	01	01	H4141_017_3	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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4141	017	3	1	01	01	H4141_017_3	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	25						25			25			25		25
H4141	017	5	1	01	01	H4141_017_5	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	0		0				25		25	0		0	0		0
H4141	017	5	1	01	01	H4141_017_5	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4141	017	5	1	01	01	H4141_017_5	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	25		25				25		25	25		25	25		25
H4141	017	5	1	01	01	H4141_017_5	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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4141	017	5	1	01	01	H4141_017_5	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	25						25			25			25		25
H4141	022	0	1	01	01	H4141_022_0	2			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	0		0				25		25	0		0	0		0
H4141	022	0	1	01	01	H4141_022_0	2			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	0		0				25		25	0		0	0		0
H4141	022	0	1	01	01	H4141_022_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4141	022	0	1	01	01	H4141_022_0	2			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	25		25				25		25	25		25	25		25
H4141	022	0	1	01	01	H4141_022_0	2			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	25						25			25			25		25
H4141	023	0	1	01	01	H4141_023_0	2			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	0		0				25		25	0		0	0		0
H4141	023	0	1	01	01	H4141_023_0	2			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	0		0				25		25	0		0	0		0
H4141	023	0	1	01	01	H4141_023_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4141	023	0	1	01	01	H4141_023_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H4141	023	0	1	01	01	H4141_023_0	2			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	25						25			25			25		25
H4141	024	0	1	01	01	H4141_024_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	0		0				25		25	0		0	0		0
H4141	024	0	1	01	01	H4141_024_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	0		0				25		25	0		0	0		0
H4141	024	0	1	01	01	H4141_024_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4141	024	0	1	01	01	H4141_024_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4141	024	0	1	01	01	H4141_024_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	25						25			25			25		25
H4141	025	0	1	01	01	H4141_025_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	0		0				25		25	0		0	0		0
H4141	025	0	1	01	01	H4141_025_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	0		0				25		25	0		0	0		0
H4141	025	0	1	01	01	H4141_025_0	4		N	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	0		0				25		25	0		0	0		0
H4141	025	0	1	01	01	H4141_025_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4141	025	0	1	01	01	H4141_025_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	25						25			25			25		25
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	0	0	0					25	25		0	0	0		0
H4152	013	0	1	02	01	H4152_013_0	6			Generic	4	11	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	0.00	0.00	0.00																										32.00	48.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00					32.00	48.00		0.00	0.00	0.00		0.00	0	0	0					25	25		0	0	0		0
H4152	013	0	1	02	01	H4152_013_0	6			Preferred Brand	4	11	1	1	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31				59.12	25	25	25																									25	25					25	25			25			25								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	25	25	25					25	25		25	25	25		25
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				65.38	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	25	25	25					25	25		25	25	25		25
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					27																										27						27					27			27								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	0	0	0					25	25		0	0	0		0
H4152	018	0	1	02	01	H4152_018_0	6			Generic	4	11	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	0	0	0					25	25		0	0	0		0
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	25	25	25					25	25		25	25	25		25
H4152	018	0	1	02	01	H4152_018_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31				64.59	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	25	25	25					25	25		25	25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4152	021	0	1	01	01	H4152_021_0	6		N	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	0	0	0					25	25		0	0	0		0
H4152	021	0	1	01	01	H4152_021_0	6		N	Generic	4	11	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	0.00	0.00	0.00																										32.00	48.00					0.00	0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00					32.00	48.00		0.00	0.00	0.00		0.00	0	0	0					25	25		0	0	0		0
H4152	021	0	1	01	01	H4152_021_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31				59.78	25	25	25																									25	25					25	25			25			25								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	25	25	25					25	25		25	25	25		25
H4152	021	0	1	01	01	H4152_021_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31				60.85	29	29	29																									29	29					29	29			29			29								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	25	25	25					25	25		25	25	25		25
H4152	021	0	1	01	01	H4152_021_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																														
H4152	023	0	1	02	01	H4152_023_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	0	0	0					25	25		0	0	0		0
H4152	023	0	1	02	01	H4152_023_0	6			Generic	4	11	1	2	2	1	111		01		101	1	30	60	100				1	2					60	100	30		31	2.00	4.00	6.00																										32.00	48.00					0.00	0.00				2.00				2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00	4.00	6.00					32.00	48.00		0.00	0.00	2.00		2.00	25	25	25					25	25		0	0	25		25
H4152	023	0	1	02	01	H4152_023_0	6			Preferred Brand	4	11	1	1	3	1	111		01		101	1	30	60	100				1	2					60	100	30		31				58.51	25	25	25																									25	25					25	25			25			25								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	25	25	25					25	25		25	25	25		25
H4152	023	0	1	02	01	H4152_023_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01		101	1	30	60	100				1	2					60	100	30		31				64.89	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	25	25	25					25	25		25	25	25		25
H4152	023	0	1	02	01	H4152_023_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																														
H4158	001	0	1	01	01	H4158_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4158	001	0	1	01	01	H4158_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4158	001	0	1	01	01	H4158_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.75	25	25	25				104.75	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4158	001	0	1	01	01	H4158_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4158	001	0	1	01	01	H4158_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4158	001	0	1	01	01	H4158_001_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	002	0	1	02	01	H4161_002_0	5			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	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																														
H4161	002	0	1	02	01	H4161_002_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	002	0	1	02	01	H4161_002_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											29.00	25	25	25				20.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	002	0	1	02	01	H4161_002_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																														
H4161	003	0	1	02	01	H4161_003_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	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																														
H4161	003	0	1	02	01	H4161_003_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	003	0	1	02	01	H4161_003_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											38.00	25	25	25				26.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	003	0	1	02	01	H4161_003_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																														
H4161	004	0	1	02	01	H4161_004_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	004	0	1	02	01	H4161_004_0	5			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																														
H4161	004	0	1	02	01	H4161_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											55.00	20	20	20				52.00	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	105.00				35.00		35.00	20	20	20	15	15	15	15	15	15				20		20
H4161	004	0	1	02	01	H4161_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											35.00	30	30	30				20.00	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	25	25	25	25	25	25	25	25	25				25		25
H4161	004	0	1	02	01	H4161_004_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																														
H4161	005	0	1	02	01	H4161_005_0	5			Preferred Generic	4	11	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4161	005	0	1	02	01	H4161_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											82.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	005	0	1	02	01	H4161_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											42.00	30	30	30				24.00	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	25	25	25	25	25	25	25	25	25				25		25
H4161	005	0	1	02	01	H4161_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4161	006	0	1	02	01	H4161_006_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																														
H4161	006	0	1	02	01	H4161_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																														
H4161	006	0	1	02	01	H4161_006_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	126.00	126.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	006	0	1	02	01	H4161_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											24.00	25	25	25				12.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	006	0	1	02	01	H4161_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																														
H4161	007	0	1	02	01	H4161_007_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																														
H4161	007	0	1	02	01	H4161_007_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4161	007	0	1	02	01	H4161_007_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	007	0	1	02	01	H4161_007_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											43.00	30	30	30				28.00	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	25	25	25	25	25	25	25	25	25				25		25
H4161	007	0	1	02	01	H4161_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4161	009	0	1	02	01	H4161_009_0	5			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	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																														
H4161	009	0	1	02	01	H4161_009_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								47.00	94.00	141.00					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	009	0	1	02	01	H4161_009_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											41.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	009	0	1	02	01	H4161_009_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																														
H4161	010	0	1	02	01	H4161_010_0	5			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	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																														
H4161	010	0	1	02	01	H4161_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					42.00	84.00	126.00					42.00	84.00	84.00																47.00				47.00			1.57	1.40	1.40			1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	010	0	1	02	01	H4161_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											43.00	25	25	25				23.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	010	0	1	02	01	H4161_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																														
H4161	011	0	1	02	01	H4161_011_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	011	0	1	02	01	H4161_011_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											73.00	25	25	25				112.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4161	011	0	1	02	01	H4161_011_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											66.00	30	30	30				56.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	011	0	1	02	01	H4161_011_0	4			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																														
H4161	011	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4161	012	0	1	02	01	H4161_012_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	012	0	1	02	01	H4161_012_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.00	25	25	25				113.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4161	012	0	1	02	01	H4161_012_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											64.00	30	30	30				50.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	012	0	1	02	01	H4161_012_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	012	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4161	013	0	1	02	01	H4161_013_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	013	0	1	02	01	H4161_013_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.00	25	25	25				111.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4161	013	0	1	02	01	H4161_013_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											62.00	30	30	30				51.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	013	0	1	02	01	H4161_013_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	013	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4161	014	0	1	02	01	H4161_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																														
H4161	014	0	1	02	01	H4161_014_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	014	0	1	02	01	H4161_014_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.00	25	25	25				80.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H4161	014	0	1	02	01	H4161_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											76.00	30	30	30				40.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	014	0	1	02	01	H4161_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																														
H4161	014	0	1	02	01	H4161_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	0	0	0	0	0	0	0	0	0				0		0
H4161	015	0	1	02	01	H4161_015_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																														
H4161	015	0	1	02	01	H4161_015_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	015	0	1	02	01	H4161_015_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											83.00	25	25	25				81.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H4161	015	0	1	02	01	H4161_015_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											76.00	30	30	30				41.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	015	0	1	02	01	H4161_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	015	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4161	016	0	1	02	01	H4161_016_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																														
H4161	016	0	1	02	01	H4161_016_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	016	0	1	02	01	H4161_016_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											85.00	25	25	25				90.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H4161	016	0	1	02	01	H4161_016_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											50.00	30	30	30				35.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	016	0	1	02	01	H4161_016_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																														
H4161	016	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4161	017	0	1	02	01	H4161_017_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																														
H4161	017	0	1	02	01	H4161_017_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4161	017	0	1	02	01	H4161_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											82.00	25	25	25				88.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H4161	017	0	1	02	01	H4161_017_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											48.00	30	30	30				33.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4161	017	0	1	02	01	H4161_017_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																														
H4161	017	0	1	02	01	H4161_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4172	003	0	1	01	01	H4172_003_0	6			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				1	2								10	31	2.00	4.00	6.00																																						2.00			2.00		0.07						0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4172	003	0	1	01	01	H4172_003_0	6			Generic	4	01	1	2	2	1	111		10			1	30	60	90				1	2								10	31	15.00	30.00	45.00																																						15.00			15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4172	003	0	1	01	01	H4172_003_0	6			Preferred Brand	4	10	1	2	3	1	111		10			1	30	60	90				1	2								10	31	45.00	90.00	135.00																																						45.00			45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H4172	003	0	1	01	01	H4172_003_0	6			Non-Preferred Drug	4	10	1	2	4	1	111		10			1	30	60	90				1	2								10	31	95.00	190.00	285.00																																						95.00			95.00		3.17						3.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H4172	003	0	1	01	01	H4172_003_0	6			Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				553.13	30																																						30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	1	1	09	04	H4213_017_1	5			Preferred Generic	3	11	1	2	1	1	110		01			1	30		100				1	2							30		31	5.00		12.50																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	1	1	09	04	H4213_017_1	5			Generic	3	11	1	2	2	1	110		01			1	30		100				1	2							30		31	12.00		30.00																																					12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	1	1	09	04	H4213_017_1	5			Preferred Brand	3	11	1	1	3	1	110		01			1	30		100				1	2							30		31				33.00	20		20																																			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	20		20										20		20
H4213	017	1	1	09	04	H4213_017_1	5			Non-Preferred Drug	3	11	1	1	4	1	110		01			1	30		100				1	2							30		31				60.85	30		30																																			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H4213	017	1	1	09	04	H4213_017_1	5			Specialty Tier	3	11	1	1	5	1	010		01			1	30														30		31				626.48	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H4213	017	5	1	09	04	H4213_017_5	5			Preferred Generic	3	11	1	2	1	1	110		01			1	30		100				1	2							30		31	5.00		12.50																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	5	1	09	04	H4213_017_5	5			Generic	3	11	1	2	2	1	110		01			1	30		100				1	2							30		31	12.00		30.00																																					12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	5	1	09	04	H4213_017_5	5			Preferred Brand	3	11	1	1	3	1	110		01			1	30		100				1	2							30		31				33.00	20		20																																			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	20		20										20		20
H4213	017	5	1	09	04	H4213_017_5	5			Non-Preferred Drug	3	11	1	1	4	1	110		01			1	30		100				1	2							30		31				60.85	30		30																																			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H4213	017	5	1	09	04	H4213_017_5	5			Specialty Tier	3	11	1	1	5	1	010		01			1	30														30		31				626.48	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H4213	017	6	1	09	04	H4213_017_6	5			Preferred Generic	3	11	1	2	1	1	110		01			1	30		100				1	2							30		31	5.00		12.50																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	6	1	09	04	H4213_017_6	5			Generic	3	11	1	2	2	1	110		01			1	30		100				1	2							30		31	12.00		30.00																																					12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4213	017	6	1	09	04	H4213_017_6	5			Preferred Brand	3	11	1	1	3	1	110		01			1	30		100				1	2							30		31				33.00	20		20																																			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	20		20										20		20
H4213	017	6	1	09	04	H4213_017_6	5			Non-Preferred Drug	3	11	1	1	4	1	110		01			1	30		100				1	2							30		31				60.85	30		30																																			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H4213	017	6	1	09	04	H4213_017_6	5			Specialty Tier	3	11	1	1	5	1	010		01			1	30														30		31				626.48	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H4227	001	0	1	01	01	H4227_001_0	5		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				5.17	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4227	001	0	1	01	01	H4227_001_0	5		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				15.62	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	001	0	1	01	01	H4227_001_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				94.71	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	001	0	1	01	01	H4227_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				22.49	26	26	26																			26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	001	0	1	01	01	H4227_001_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				501.34	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4227	001	0	1	01	01	H4227_001_0	5		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4227	002	0	1	01	01	H4227_002_0	5		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				5.08	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4227	002	0	1	01	01	H4227_002_0	5		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				12.92	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	002	0	1	01	01	H4227_002_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				89.73	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	002	0	1	01	01	H4227_002_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				21.24	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4227	002	0	1	01	01	H4227_002_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				438.27	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4227	002	0	1	01	01	H4227_002_0	5		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4279	001	0	1	01	01	H4279_001_0	17		N	Preferred Generic	2	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H4279	001	0	1	01	01	H4279_001_0	17		N	Generic	2	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	0	0	0				0	0	0				0		0
H4279	001	0	1	01	01	H4279_001_0	17		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.17	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4279	001	0	1	01	01	H4279_001_0	17		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				38.68	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4279	001	0	1	01	01	H4279_001_0	17		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	30								30						30		31				657.97	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4279	004	0	1	01	01	H4279_004_0	18		N	Preferred Generic	2	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H4279	004	0	1	01	01	H4279_004_0	18		N	Generic	2	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	0	0	0				0	0	0				0		0
H4279	004	0	1	01	01	H4279_004_0	18		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				38.89	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4279	004	0	1	01	01	H4279_004_0	18		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				42.14	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4279	004	0	1	01	01	H4279_004_0	18		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	30								30						30		31				650.60	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4286	001	0	1	01	01	H4286_001_0	6			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	25	25	25	0	0	0							25		25
H4286	001	0	1	01	01	H4286_001_0	6			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	25	25	25	0	0	0							25		25
H4286	001	0	1	01	01	H4286_001_0	6			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	25			25									25		25
H4286	001	0	1	01	01	H4286_001_0	6			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											364.32	33						151.55	33																							33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H4286	001	0	1	01	01	H4286_001_0	6			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	6		N	Generic	4	01	1	1	1	1		111	01			1				30	60	90	2	2							30		31											3.41	20	20	20				2.57	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	20	20	20	20	20	20							20		20
H4286	002	0	1	01	01	H4286_002_0	6		N	Preferred Brand	4	11	1	1	2	1		111	01			1				30	60	90	2	2							30		31											53.41	20	20	20				57.21	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	20	20	20	20	20	20							20		20
H4286	002	0	1	01	01	H4286_002_0	6		N	Non-Preferred Drug	4	11	1	1	3	1		010	01			1				30											30		31											100.26	25						53.48	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00			35.00									35.00		35.00	25			25									25		25
H4286	002	0	1	01	01	H4286_002_0	6		N	Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											50.70	25						68.75	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H4286	002	0	1	01	01	H4286_002_0	6		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	6			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	25	25	25	25	25	25							25		25
H4286	003	0	1	01	01	H4286_003_0	6			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	25	25	25	25	25	25							25		25
H4286	003	0	1	01	01	H4286_003_0	6			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	25			25									25		25
H4286	003	0	1	01	01	H4286_003_0	6			Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											594.47	33						178.21	33																							33			33								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H4286	003	0	1	01	01	H4286_003_0	6			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	6		N	Generic	4	01	1	1	1	1		111	01			1				30	60	90	2	2							30		31											3.41	20	20	20				2.57	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	20	20	20	20	20	20							20		20
H4286	005	0	1	01	01	H4286_005_0	6		N	Preferred Brand	4	11	1	1	2	1		111	01			1				30	60	90	2	2							30		31											53.41	20	20	20				57.21	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	20	20	20	20	20	20							20		20
H4286	005	0	1	01	01	H4286_005_0	6		N	Non-Preferred Drug	4	11	1	1	3	1		010	01			1				30											30		31											100.26	25						53.48	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00			35.00									35.00		35.00	25			25									25		25
H4286	005	0	1	01	01	H4286_005_0	6		N	Specialty Tier	4	11	1	1	4	1		010	01			1				30											30		31											50.70	25						68.75	25																							25			25								Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H4286	005	0	1	01	01	H4286_005_0	6		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																														
H4329	001	0	1	01	01	H4329_001_0	3		N	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				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
H4329	001	0	1	01	01	H4329_001_0	3		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, Select Care Drugs	0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
H4329	001	0	1	01	01	H4329_001_0	3		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				46.00	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	0		0				0		0	0		0	0		0
H4329	001	0	1	01	01	H4329_001_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				44.00	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	0		0				0		0	0		0	0		0
H4329	001	0	1	01	01	H4329_001_0	3		N	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	0.00						0.00			0.00			0.00		0.00	0						0			0			0		0
H4329	001	0	1	01	01	H4329_001_0	3		N	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	0		0				0		0	0		0	0		0
H4346	001	0	1	02	01	H4346_001_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	001	0	1	02	01	H4346_001_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											65.00	25	25	25				105.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4346	001	0	1	02	01	H4346_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											45.00	30	30	30				43.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4346	001	0	1	02	01	H4346_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	001	0	1	02	01	H4346_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H4346	005	0	1	02	01	H4346_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	005	0	1	02	01	H4346_005_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	005	0	1	02	01	H4346_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											75.00	20	20	20				80.00	15	15	15				15	15	15															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	20	20	20	15	15	15	15	15	15				20		20
H4346	005	0	1	02	01	H4346_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											48.00	30	30	30				24.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4346	005	0	1	02	01	H4346_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																														
H4346	005	0	1	02	01	H4346_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	0	0	0	0	0	0	0	0	0				0		0
H4346	006	0	1	02	01	H4346_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																														
H4346	006	0	1	02	01	H4346_006_0	5			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																														
H4346	006	0	1	02	01	H4346_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											75.00	25	25	25				77.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H4346	006	0	1	02	01	H4346_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											70.00	30	30	30				25.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4346	006	0	1	02	01	H4346_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																														
H4346	006	0	1	02	01	H4346_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	0	0	0	0	0	0	0	0	0				0		0
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				102.00	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
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				56.00	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		35.00	25	25	25				25	25	25				25		25
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	0	0	0				0	0	0				0		0
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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	012	0	1	01	01	H4346_012_0	7			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	012	0	1	01	01	H4346_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				70.00	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	105.00				35.00		35.00	25	25	25	20	20	20	20	20	20				25		25
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											33.00	30	30	30				23.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
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												29							29						29																	29			29								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	014	0	1	01	01	H4346_014_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	014	0	1	01	01	H4346_014_0	7		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, Select Care Drugs																														
H4346	014	0	1	01	01	H4346_014_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				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4346	014	0	1	01	01	H4346_014_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				34.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4346	014	0	1	01	01	H4346_014_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, Select Care Drugs																														
H4346	014	0	1	01	01	H4346_014_0	7		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																														
H4346	017	0	1	02	01	H4346_017_0	4			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	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4346	017	0	1	02	01	H4346_017_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.00	25	25	25				90.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H4346	017	0	1	02	01	H4346_017_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											33.00	30	30	30				21.00	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	25	25	25	25	25	25	25	25	25				25		25
H4346	017	0	1	02	01	H4346_017_0	4			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																														
H4346	025	0	1	01	01	H4346_025_0	6		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																														
H4346	025	0	1	01	01	H4346_025_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																														
H4346	025	0	1	01	01	H4346_025_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				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	25	25	25				25	25	25				25		25
H4346	025	0	1	01	01	H4346_025_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				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	25	25	25				25	25	25				25		25
H4346	025	0	1	01	01	H4346_025_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4346	030	0	1	02	01	H4346_030_0	4			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	030	0	1	02	01	H4346_030_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	030	0	1	02	01	H4346_030_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.00	25	25	25				87.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H4346	030	0	1	02	01	H4346_030_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											63.00	30	30	30				54.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4346	030	0	1	02	01	H4346_030_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4346	030	0	1	02	01	H4346_030_0	4			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	0	0	0	0	0	0	0	0	0				0		0
H4346	031	0	1	01	01	H4346_031_0	6		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																														
H4346	031	0	1	01	01	H4346_031_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																														
H4346	031	0	1	01	01	H4346_031_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				107.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4346	031	0	1	01	01	H4346_031_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				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	25	25	25				25	25	25				25		25
H4346	031	0	1	01	01	H4346_031_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																														
H4348	001	0	1	04	01	H4348_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	0	0	0				0	0	0				0		0
H4348	001	0	1	04	01	H4348_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4348	001	0	1	04	01	H4348_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				33.00	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	19	19	19				19	19	19				19		19
H4348	001	0	1	04	01	H4348_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4348	001	0	1	04	01	H4348_001_0	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	25						25						25		25
H4348	002	0	1	04	01	H4348_002_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	0	0	0				0	0	0				0		0
H4348	002	0	1	04	01	H4348_002_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	25	25	25				25	25	25				25		25
H4348	002	0	1	04	01	H4348_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				39.00	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	21	21	21				21	21	21				21		21
H4348	002	0	1	04	01	H4348_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				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	25	25	25				25	25	25				25		25
H4348	002	0	1	04	01	H4348_002_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	25						25						25		25
H4348	003	0	1	04	01	H4348_003_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H4348	003	0	1	04	01	H4348_003_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H4348	003	0	1	04	01	H4348_003_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H4348	003	0	1	04	01	H4348_003_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H4348	003	0	1	04	01	H4348_003_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4348	003	0	1	04	01	H4348_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4348	004	0	1	04	01	H4348_004_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H4348	004	0	1	04	01	H4348_004_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H4348	004	0	1	04	01	H4348_004_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4348	004	0	1	04	01	H4348_004_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H4348	004	0	1	04	01	H4348_004_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4348	004	0	1	04	01	H4348_004_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4348	005	0	1	04	01	H4348_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H4348	005	0	1	04	01	H4348_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4348	005	0	1	04	01	H4348_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				33.00	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	19	19	19				19	19	19				19		19
H4348	005	0	1	04	01	H4348_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				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	25	25	25				25	25	25				25		25
H4348	005	0	1	04	01	H4348_005_0	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	25						25						25		25
H4348	006	0	1	04	01	H4348_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	0	0	0				0	0	0				0		0
H4348	006	0	1	04	01	H4348_006_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	25	25	25				25	25	25				25		25
H4348	006	0	1	04	01	H4348_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				39.00	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	21	21	21				21	21	21				21		21
H4348	006	0	1	04	01	H4348_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				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	25	25	25				25	25	25				25		25
H4348	006	0	1	04	01	H4348_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	25						25						25		25
H4348	007	0	1	04	01	H4348_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H4348	007	0	1	04	01	H4348_007_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H4348	007	0	1	04	01	H4348_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H4348	007	0	1	04	01	H4348_007_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H4348	007	0	1	04	01	H4348_007_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4348	007	0	1	04	01	H4348_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4407	004	0	1	01	01	H4407_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	004	0	1	01	01	H4407_004_0	5		N	Generic	4	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					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	0.35	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	004	0	1	01	01	H4407_004_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											20.21	24	24	24				23.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4407	004	0	1	01	01	H4407_004_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											49.97	25	25	25				54.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	004	0	1	01	01	H4407_004_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											446.86	25						400.03	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	25			25			25			25			25		25
H4407	027	0	1	01	01	H4407_027_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	027	0	1	01	01	H4407_027_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	027	0	1	01	01	H4407_027_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	027	0	1	01	01	H4407_027_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											40.95	50	50	50				55.55	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	027	0	1	01	01	H4407_027_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											600.32	30						453.89	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	25			25			25			25			25		25
H4407	029	0	1	01	01	H4407_029_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	029	0	1	01	01	H4407_029_0	5		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	029	0	1	01	01	H4407_029_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											20.58	23	23	23				22.58	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4407	029	0	1	01	01	H4407_029_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											45.74	25	25	25				55.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	029	0	1	01	01	H4407_029_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											462.83	25						393.75	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	25			25			25			25			25		25
H4407	030	1	1	01	01	H4407_030_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	030	1	1	01	01	H4407_030_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	030	1	1	01	01	H4407_030_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	1	1	01	01	H4407_030_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											42.98	50	50	50				56.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	1	1	01	01	H4407_030_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											592.69	30						515.64	30												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	25			25			25			25			25		25
H4407	030	2	1	01	01	H4407_030_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	030	2	1	01	01	H4407_030_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	030	2	1	01	01	H4407_030_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	2	1	01	01	H4407_030_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											42.98	50	50	50				56.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	2	1	01	01	H4407_030_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											592.69	30						515.64	30												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	25			25			25			25			25		25
H4407	030	3	1	01	01	H4407_030_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	030	3	1	01	01	H4407_030_3	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	030	3	1	01	01	H4407_030_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	3	1	01	01	H4407_030_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											42.98	50	50	50				56.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	030	3	1	01	01	H4407_030_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											592.69	30						515.64	30												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	25			25			25			25			25		25
H4407	033	0	1	01	01	H4407_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	033	0	1	01	01	H4407_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	033	0	1	01	01	H4407_033_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	033	0	1	01	01	H4407_033_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											55.51	50	50	50				63.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	033	0	1	01	01	H4407_033_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											562.49	30						559.53	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	25			25			25			25			25		25
H4407	034	0	1	01	01	H4407_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								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	034	0	1	01	01	H4407_034_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, 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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	034	0	1	01	01	H4407_034_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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	034	0	1	01	01	H4407_034_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											33.35	50	50	50				38.65	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	034	0	1	01	01	H4407_034_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											530.51	30						403.20	30												30						30					30			30								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	25			25			25			25			25		25
H4407	034	0	1	01	01	H4407_034_0	5			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					9.00	18.00	27.00											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	27.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	035	0	1	01	01	H4407_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4407	035	0	1	01	01	H4407_035_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4407	035	0	1	01	01	H4407_035_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	035	0	1	01	01	H4407_035_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											55.51	50	50	50				63.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4407	035	0	1	01	01	H4407_035_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											562.10	30						559.41	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	25			25			25			25			25		25
H4461	022	0	1	01	01	H4461_022_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	0		0				25		25	0		0	0		0
H4461	022	0	1	01	01	H4461_022_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	0		0				25		25	0		0	0		0
H4461	022	0	1	01	01	H4461_022_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	022	0	1	01	01	H4461_022_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	022	0	1	01	01	H4461_022_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	25						25			25			25		25
H4461	025	0	1	01	01	H4461_025_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	0		0				25		25	0		0	0		0
H4461	025	0	1	01	01	H4461_025_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4461	025	0	1	01	01	H4461_025_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	25		25				25		25	25		25	25		25
H4461	025	0	1	01	01	H4461_025_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	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	25		25				25		25	25		25	25		25
H4461	025	0	1	01	01	H4461_025_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H4461	035	0	1	01	01	H4461_035_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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				76.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H4461	038	0	1	01	01	H4461_038_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	0		0				25		25	0		0	0		0
H4461	038	0	1	01	01	H4461_038_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	0		0				25		25	0		0	0		0
H4461	038	0	1	01	01	H4461_038_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	038	0	1	01	01	H4461_038_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4461	038	0	1	01	01	H4461_038_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	25						25			25			25		25
H4461	039	0	1	01	01	H4461_039_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	0		0				25		25	0		0	0		0
H4461	039	0	1	01	01	H4461_039_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	3.00		9.00																									20.00		60.00				3.00		0.00				3.00				3.00		0.10				0.67	0.10	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00		9.00				20.00		60.00	3.00		0.00	3.00		3.00	25		25				25		25	25		0	25		25
H4461	039	0	1	01	01	H4461_039_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	25		25				25		25	25		25	25		25
H4461	039	0	1	01	01	H4461_039_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	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	25		25				25		25	25		25	25		25
H4461	039	0	1	01	01	H4461_039_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	25						25			25			25		25
H4461	040	0	1	01	01	H4461_040_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	0		0				25		25	0		0	0		0
H4461	040	0	1	01	01	H4461_040_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	0		0				25		25	0		0	0		0
H4461	040	0	1	01	01	H4461_040_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	25		25				25		25	25		25	25		25
H4461	040	0	1	01	01	H4461_040_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	040	0	1	01	01	H4461_040_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	25						25			25			25		25
H4461	041	0	1	01	01	H4461_041_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	0		0				25		25	0		0	0		0
H4461	041	0	1	01	01	H4461_041_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4461	041	0	1	01	01	H4461_041_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	25		25				25		25	25		25	25		25
H4461	041	0	1	01	01	H4461_041_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	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	25		25				25		25	25		25	25		25
H4461	041	0	1	01	01	H4461_041_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
H4461	042	0	1	01	01	H4461_042_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	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H4461	043	1	1	01	01	H4461_043_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	0		0				25		25	0		0	0		0
H4461	043	1	1	01	01	H4461_043_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4461	043	1	1	01	01	H4461_043_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	25		25				25		25	25		25	25		25
H4461	043	1	1	01	01	H4461_043_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H4461	043	1	1	01	01	H4461_043_1	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	25						25			25			25		25
H4461	043	2	1	01	01	H4461_043_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	0		0				25		25	0		0	0		0
H4461	043	2	1	01	01	H4461_043_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4461	043	2	1	01	01	H4461_043_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	25		25				25		25	25		25	25		25
H4461	043	2	1	01	01	H4461_043_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H4461	043	2	1	01	01	H4461_043_2	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	25						25			25			25		25
H4461	044	0	1	02	01	H4461_044_0	4		N	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	0		0				25		25	0		0	0		0
H4461	044	0	1	02	01	H4461_044_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	0		0				25		25	0		0	0		0
H4461	044	0	1	02	01	H4461_044_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	044	0	1	02	01	H4461_044_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	044	0	1	02	01	H4461_044_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	25						25			25			25		25
H4461	045	0	1	01	01	H4461_045_0	2			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	0		0				25		25	0		0	0		0
H4461	045	0	1	01	01	H4461_045_0	2			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	25		25				25		25	25		0	25		25
H4461	045	0	1	01	01	H4461_045_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	045	0	1	01	01	H4461_045_0	2			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	25		25				25		25	25		25	25		25
H4461	045	0	1	01	01	H4461_045_0	2			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	25						25			25			25		25
H4461	046	0	1	01	01	H4461_046_0	2			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	0		0				25		25	0		0	0		0
H4461	046	0	1	01	01	H4461_046_0	2			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	25		25				25		25	25		0	25		25
H4461	046	0	1	01	01	H4461_046_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	046	0	1	01	01	H4461_046_0	2			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	25		25				25		25	25		25	25		25
H4461	046	0	1	01	01	H4461_046_0	2			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	25						25			25			25		25
H4461	047	0	1	02	01	H4461_047_0	2			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	0		0				25		25	0		0	0		0
H4461	047	0	1	02	01	H4461_047_0	2			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	25		25				25		25	25		0	25		25
H4461	047	0	1	02	01	H4461_047_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	047	0	1	02	01	H4461_047_0	2			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	25		25				25		25	25		25	25		25
H4461	047	0	1	02	01	H4461_047_0	2			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	25						25			25			25		25
H4461	048	0	1	02	01	H4461_048_0	2			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	0		0				25		25	0		0	0		0
H4461	048	0	1	02	01	H4461_048_0	2			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	0		0				25		25	0		0	0		0
H4461	048	0	1	02	01	H4461_048_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	048	0	1	02	01	H4461_048_0	2			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	25		25				25		25	25		25	25		25
H4461	048	0	1	02	01	H4461_048_0	2			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	25						25			25			25		25
H4461	049	0	1	01	01	H4461_049_0	2			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	0		0				25		25	0		0	0		0
H4461	049	0	1	01	01	H4461_049_0	2			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	25		25				25		25	25		0	25		25
H4461	049	0	1	01	01	H4461_049_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	049	0	1	01	01	H4461_049_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H4461	049	0	1	01	01	H4461_049_0	2			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	25						25			25			25		25
H4461	050	0	1	01	01	H4461_050_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	0		0				25		25	0		0	0		0
H4461	050	0	1	01	01	H4461_050_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4461	050	0	1	01	01	H4461_050_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	050	0	1	01	01	H4461_050_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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	25		25				25		25	25		25	25		25
H4461	050	0	1	01	01	H4461_050_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	25						25			25			25		25
H4461	051	0	1	01	01	H4461_051_0	2			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	0		0				25		25	0		0	0		0
H4461	051	0	1	01	01	H4461_051_0	2			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	25		25				25		25	25		0	25		25
H4461	051	0	1	01	01	H4461_051_0	2			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	25		25				25		25	25		25	25		25
H4461	051	0	1	01	01	H4461_051_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H4461	051	0	1	01	01	H4461_051_0	2			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	25						25			25			25		25
H4461	052	0	1	01	01	H4461_052_0	2			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	0		0				25		25	0		0	0		0
H4461	052	0	1	01	01	H4461_052_0	2			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	0		0				25		25	0		0	0		0
H4461	052	0	1	01	01	H4461_052_0	2			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	25		25				25		25	25		25	25		25
H4461	052	0	1	01	01	H4461_052_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H4461	052	0	1	01	01	H4461_052_0	2			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	25						25			25			25		25
H4461	053	0	1	01	01	H4461_053_0	2			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	0		0				25		25	0		0	0		0
H4461	053	0	1	01	01	H4461_053_0	2			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	0		0				25		25	0		0	0		0
H4461	053	0	1	01	01	H4461_053_0	2			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	25		25				25		25	25		25	25		25
H4461	053	0	1	01	01	H4461_053_0	2			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	25		25				25		25	25		25	25		25
H4461	053	0	1	01	01	H4461_053_0	2			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	25						25			25			25		25
H4461	054	0	1	01	01	H4461_054_0	2			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	0		0				25		25	0		0	0		0
H4461	054	0	1	01	01	H4461_054_0	2			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	0		0				25		25	0		0	0		0
H4461	054	0	1	01	01	H4461_054_0	2			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	25		25				25		25	25		25	25		25
H4461	054	0	1	01	01	H4461_054_0	2			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	25		25				25		25	25		25	25		25
H4461	054	0	1	01	01	H4461_054_0	2			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	25						25			25			25		25
H4461	055	0	1	01	01	H4461_055_0	2			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	0		0				25		25	0		0	0		0
H4461	055	0	1	01	01	H4461_055_0	2			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	25		25				25		25	25		0	25		25
H4461	055	0	1	01	01	H4461_055_0	2			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	25		25				25		25	25		25	25		25
H4461	055	0	1	01	01	H4461_055_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	25		25				25		25	25		25	25		25
H4461	055	0	1	01	01	H4461_055_0	2			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	25						25			25			25		25
H4461	056	0	1	01	01	H4461_056_0	2			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	0		0				25		25	0		0	0		0
H4461	056	0	1	01	01	H4461_056_0	2			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	25		25				25		25	25		0	25		25
H4461	056	0	1	01	01	H4461_056_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	056	0	1	01	01	H4461_056_0	2			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	25		25				25		25	25		25	25		25
H4461	056	0	1	01	01	H4461_056_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	25						25			25			25		25
H4461	057	0	1	01	01	H4461_057_0	2			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	0		0				25		25	0		0	0		0
H4461	057	0	1	01	01	H4461_057_0	2			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	25		25				25		25	25		0	25		25
H4461	057	0	1	01	01	H4461_057_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	057	0	1	01	01	H4461_057_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H4461	057	0	1	01	01	H4461_057_0	2			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	25						25			25			25		25
H4461	058	0	1	01	01	H4461_058_0	2			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	0		0				25		25	0		0	0		0
H4461	058	0	1	01	01	H4461_058_0	2			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	0		0				25		25	0		0	0		0
H4461	058	0	1	01	01	H4461_058_0	2			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	25		25				25		25	25		25	25		25
H4461	058	0	1	01	01	H4461_058_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	46		46																								46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	058	0	1	01	01	H4461_058_0	2			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	25						25			25			25		25
H4461	059	0	1	01	01	H4461_059_0	2			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	0		0				25		25	0		0	0		0
H4461	059	0	1	01	01	H4461_059_0	2			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	25		25				25		25	25		0	25		25
H4461	059	0	1	01	01	H4461_059_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	059	0	1	01	01	H4461_059_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	059	0	1	01	01	H4461_059_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	25						25			25			25		25
H4461	060	0	1	01	01	H4461_060_0	2			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	0		0				25		25	0		0	0		0
H4461	060	0	1	01	01	H4461_060_0	2			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	0		0				25		25	0		0	0		0
H4461	060	0	1	01	01	H4461_060_0	2			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	25		25				25		25	25		25	25		25
H4461	060	0	1	01	01	H4461_060_0	2			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	25		25				25		25	25		25	25		25
H4461	060	0	1	01	01	H4461_060_0	2			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	25						25			25			25		25
H4461	061	0	1	01	01	H4461_061_0	2			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	0		0				25		25	0		0	0		0
H4461	061	0	1	01	01	H4461_061_0	2			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	0		0				25		25	0		0	0		0
H4461	061	0	1	01	01	H4461_061_0	2			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	25		25				25		25	25		25	25		25
H4461	061	0	1	01	01	H4461_061_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	061	0	1	01	01	H4461_061_0	2			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	25						25			25			25		25
H4461	062	0	1	01	01	H4461_062_0	2			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	0		0				25		25	0		0	0		0
H4461	062	0	1	01	01	H4461_062_0	2			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	25		25				25		25	25		0	25		25
H4461	062	0	1	01	01	H4461_062_0	2			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	25		25				25		25	25		25	25		25
H4461	062	0	1	01	01	H4461_062_0	2			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	25		25				25		25	25		25	25		25
H4461	062	0	1	01	01	H4461_062_0	2			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	25						25			25			25		25
H4461	063	0	1	01	01	H4461_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, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H4461	063	0	1	01	01	H4461_063_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	25		25				25		25	25		0	25		25
H4461	063	0	1	01	01	H4461_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	063	0	1	01	01	H4461_063_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	063	0	1	01	01	H4461_063_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	25						25			25			25		25
H4461	063	0	1	01	01	H4461_063_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	0		0				0		0	0		0	0		0
H4461	064	0	1	01	01	H4461_064_0	2			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	0		0				25		25	0		0	0		0
H4461	064	0	1	01	01	H4461_064_0	2			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	25		25				25		25	25		0	25		25
H4461	064	0	1	01	01	H4461_064_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	064	0	1	01	01	H4461_064_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H4461	064	0	1	01	01	H4461_064_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	25						25			25			25		25
H4461	065	0	1	01	01	H4461_065_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	0		0				25		25	0		0	0		0
H4461	065	0	1	01	01	H4461_065_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	25		25				25		25	25		0	25		25
H4461	065	0	1	01	01	H4461_065_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	065	0	1	01	01	H4461_065_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	065	0	1	01	01	H4461_065_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	25						25			25			25		25
H4461	065	0	1	01	01	H4461_065_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	0		0				0		0	0		0	0		0
H4461	066	0	1	01	01	H4461_066_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	0		0				25		25	0		0	0		0
H4461	066	0	1	01	01	H4461_066_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H4461	066	0	1	01	01	H4461_066_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	066	0	1	01	01	H4461_066_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	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	25		25				25		25	25		25	25		25
H4461	066	0	1	01	01	H4461_066_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	25						25			25			25		25
H4461	066	0	1	01	01	H4461_066_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	0		0				0		0	0		0	0		0
H4461	067	0	1	01	01	H4461_067_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	0		0				25		25	0		0	0		0
H4461	067	0	1	01	01	H4461_067_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	25		25				25		25	25		0	25		25
H4461	067	0	1	01	01	H4461_067_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	067	0	1	01	01	H4461_067_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	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	25		25				25		25	25		25	25		25
H4461	067	0	1	01	01	H4461_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	25						25			25			25		25
H4461	067	0	1	01	01	H4461_067_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	0		0				0		0	0		0	0		0
H4461	068	0	1	01	01	H4461_068_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	0		0				25		25	0		0	0		0
H4461	068	0	1	01	01	H4461_068_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H4461	068	0	1	01	01	H4461_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		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	068	0	1	01	01	H4461_068_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	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	25		25				25		25	25		25	25		25
H4461	068	0	1	01	01	H4461_068_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	25						25			25			25		25
H4461	068	0	1	01	01	H4461_068_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	0		0				0		0	0		0	0		0
H4461	069	0	1	01	01	H4461_069_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	0		0				25		25	0		0	0		0
H4461	069	0	1	01	01	H4461_069_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	0		0				25		25	0		0	0		0
H4461	069	0	1	01	01	H4461_069_0	4		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	25		25				25		25	25		25	25		25
H4461	069	0	1	01	01	H4461_069_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	069	0	1	01	01	H4461_069_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	25						25			25			25		25
H4461	070	0	1	01	01	H4461_070_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	0		0				25		25	0		0	0		0
H4461	070	0	1	01	01	H4461_070_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	0		0				25		25	0		0	0		0
H4461	070	0	1	01	01	H4461_070_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	070	0	1	01	01	H4461_070_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	070	0	1	01	01	H4461_070_0	4		N	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	25						25			25			25		25
H4461	071	0	1	01	01	H4461_071_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	0		0				25		25	0		0	0		0
H4461	071	0	1	01	01	H4461_071_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	0		0				25		25	0		0	0		0
H4461	071	0	1	01	01	H4461_071_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	071	0	1	01	01	H4461_071_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	071	0	1	01	01	H4461_071_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	25						25			25			25		25
H4461	072	0	1	01	01	H4461_072_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	0		0				25		25	0		0	0		0
H4461	072	0	1	01	01	H4461_072_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	0		0				25		25	0		0	0		0
H4461	072	0	1	01	01	H4461_072_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	072	0	1	01	01	H4461_072_0	4		N	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	25		25				25		25	25		25	25		25
H4461	072	0	1	01	01	H4461_072_0	4		N	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	25						25			25			25		25
H4461	073	0	1	01	01	H4461_073_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	0		0				25		25	0		0	0		0
H4461	073	0	1	01	01	H4461_073_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	0		0				25		25	0		0	0		0
H4461	073	0	1	01	01	H4461_073_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	25		25				25		25	25		25	25		25
H4461	073	0	1	01	01	H4461_073_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	25		25				25		25	25		25	25		25
H4461	073	0	1	01	01	H4461_073_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	25						25			25			25		25
H4461	074	0	1	01	01	H4461_074_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	0		0				25		25	0		0	0		0
H4461	074	0	1	01	01	H4461_074_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	0		0				25		25	0		0	0		0
H4461	074	0	1	01	01	H4461_074_0	4		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H4461	074	0	1	01	01	H4461_074_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	074	0	1	01	01	H4461_074_0	4		N	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	25						25			25			25		25
H4461	076	0	1	01	01	H4461_076_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	0		0				25		25	0		0	0		0
H4461	076	0	1	01	01	H4461_076_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	0		0				25		25	0		0	0		0
H4461	076	0	1	01	01	H4461_076_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4461	076	0	1	01	01	H4461_076_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4461	076	0	1	01	01	H4461_076_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	25						25			25			25		25
H4461	077	0	1	01	01	H4461_077_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	0		0				25		25	0		0	0		0
H4461	077	0	1	01	01	H4461_077_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	0		0				25		25	0		0	0		0
H4461	077	0	1	01	01	H4461_077_0	4		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H4461	077	0	1	01	01	H4461_077_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4461	077	0	1	01	01	H4461_077_0	4		N	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	25						25			25			25		25
H4461	078	0	1	01	01	H4461_078_0	2			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	0		0				25		25	0		0	0		0
H4461	078	0	1	01	01	H4461_078_0	2			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	25		25				25		25	25		0	25		25
H4461	078	0	1	01	01	H4461_078_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	078	0	1	01	01	H4461_078_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H4461	078	0	1	01	01	H4461_078_0	2			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	25						25			25			25		25
H4461	079	0	1	01	01	H4461_079_0	2			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	0		0				25		25	0		0	0		0
H4461	079	0	1	01	01	H4461_079_0	2			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	0		0				25		25	0		0	0		0
H4461	079	0	1	01	01	H4461_079_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H4461	079	0	1	01	01	H4461_079_0	2			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	25		25				25		25	25		25	25		25
H4461	079	0	1	01	01	H4461_079_0	2			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	25						25			25			25		25
H4471	005	0	1	01	01	H4471_005_0	5		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	005	0	1	01	01	H4471_005_0	5		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4471	005	0	1	01	01	H4471_005_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				115.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4471	005	0	1	01	01	H4471_005_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		34				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	25	25	25				25	25	25				25		25
H4471	005	0	1	01	01	H4471_005_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4471	010	1	1	01	01	H4471_010_1	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	010	1	1	01	01	H4471_010_1	7		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4471	010	1	1	01	01	H4471_010_1	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				121.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4471	010	1	1	01	01	H4471_010_1	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				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	25	25	25				25	25	25				25		25
H4471	010	1	1	01	01	H4471_010_1	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																														
H4471	010	2	1	01	01	H4471_010_2	5		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	010	2	1	01	01	H4471_010_2	5		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4471	010	2	1	01	01	H4471_010_2	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				121.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4471	010	2	1	01	01	H4471_010_2	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				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	25	25	25				25	25	25				25		25
H4471	010	2	1	01	01	H4471_010_2	5		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																														
H4471	011	0	1	01	01	H4471_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4471	011	0	1	01	01	H4471_011_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, Select Care Drugs																														
H4471	011	0	1	01	01	H4471_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				76.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4471	011	0	1	01	01	H4471_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				33.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4471	011	0	1	01	01	H4471_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																														
H4471	011	0	1	01	01	H4471_011_0	6		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																														
H4473	001	0	1	04	01	H4473_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	0	0	0				0	0	0				0		0
H4473	001	0	1	04	01	H4473_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4473	001	0	1	04	01	H4473_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				33.00	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	19	19	19				19	19	19				19		19
H4473	001	0	1	04	01	H4473_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4473	001	0	1	04	01	H4473_001_0	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	25						25						25		25
H4473	002	0	1	04	01	H4473_002_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	0	0	0				0	0	0				0		0
H4473	002	0	1	04	01	H4473_002_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	25	25	25				25	25	25				25		25
H4473	002	0	1	04	01	H4473_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				39.00	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	21	21	21				21	21	21				21		21
H4473	002	0	1	04	01	H4473_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				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	25	25	25				25	25	25				25		25
H4473	002	0	1	04	01	H4473_002_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	25						25						25		25
H4473	003	0	1	04	01	H4473_003_0	7			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H4473	003	0	1	04	01	H4473_003_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H4473	003	0	1	04	01	H4473_003_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H4473	003	0	1	04	01	H4473_003_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H4473	003	0	1	04	01	H4473_003_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4473	003	0	1	04	01	H4473_003_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4473	004	0	1	04	01	H4473_004_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H4473	004	0	1	04	01	H4473_004_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4473	004	0	1	04	01	H4473_004_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				48.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4473	004	0	1	04	01	H4473_004_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				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4473	004	0	1	04	01	H4473_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4473	004	0	1	04	01	H4473_004_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4473	007	0	1	04	01	H4473_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H4473	007	0	1	04	01	H4473_007_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H4473	007	0	1	04	01	H4473_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4473	007	0	1	04	01	H4473_007_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H4473	007	0	1	04	01	H4473_007_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4473	007	0	1	04	01	H4473_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	1	1	04	01	H4497_001_1	15			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	1	1	04	01	H4497_001_1	15			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	1	1	04	01	H4497_001_1	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.02	23	23	23				45.79	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4497	001	1	1	04	01	H4497_001_1	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.13	43	43	43				51.12	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	001	1	1	04	01	H4497_001_1	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	1	1	04	01	H4497_001_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	3	1	04	01	H4497_001_3	15			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								8.00	16.00	16.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				8.00				8.00			0.27	0.00		0.23	0.00	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	3	1	04	01	H4497_001_3	15			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	3	1	04	01	H4497_001_3	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.02	23	23	23				45.79	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4497	001	3	1	04	01	H4497_001_3	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.13	43	43	43				51.12	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	001	3	1	04	01	H4497_001_3	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	001	3	1	04	01	H4497_001_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	002	1	1	04	01	H4497_002_1	15			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, Select Care Drugs																														
H4497	002	1	1	04	01	H4497_002_1	15			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	002	1	1	04	01	H4497_002_1	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.62	22	22	22				38.02	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4497	002	1	1	04	01	H4497_002_1	15			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	40	40	40				50.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	002	1	1	04	01	H4497_002_1	15			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, Select Care Drugs																														
H4497	002	1	1	04	01	H4497_002_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	002	3	1	04	01	H4497_002_3	15			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, Select Care Drugs																														
H4497	002	3	1	04	01	H4497_002_3	15			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								12.00	24.00	30.00					5.00	10.00	13.00											11.00	22.00	28.00				4.00	8.00	10.00				12.00				12.00			0.40	0.17		0.37	0.13	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	002	3	1	04	01	H4497_002_3	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.62	22	22	22				38.02	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4497	002	3	1	04	01	H4497_002_3	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											47.87	40	40	40				50.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	002	3	1	04	01	H4497_002_3	15			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, Select Care Drugs																														
H4497	002	3	1	04	01	H4497_002_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	003	1	1	04	01	H4497_003_1	14			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, Select Care Drugs																														
H4497	003	1	1	04	01	H4497_003_1	14			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, Select Care Drugs																														
H4497	003	1	1	04	01	H4497_003_1	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.21	23	23	23				37.86	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4497	003	1	1	04	01	H4497_003_1	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.19	43	43	43				43.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	003	1	1	04	01	H4497_003_1	14			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, Select Care Drugs																														
H4497	003	1	1	04	01	H4497_003_1	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	003	3	1	04	01	H4497_003_3	14			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, Select Care Drugs																														
H4497	003	3	1	04	01	H4497_003_3	14			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, Select Care Drugs																														
H4497	003	3	1	04	01	H4497_003_3	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											32.21	23	23	23				37.86	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4497	003	3	1	04	01	H4497_003_3	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											42.19	43	43	43				43.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	003	3	1	04	01	H4497_003_3	14			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, Select Care Drugs																														
H4497	003	3	1	04	01	H4497_003_3	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	005	3	1	04	01	H4497_005_3	14			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	15.00					0.00	0.00	0.00											6.00	12.00	14.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	005	3	1	04	01	H4497_005_3	14			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	20.00					0.00	0.00	0.00											8.00	16.00	19.00				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																														
H4497	005	3	1	04	01	H4497_005_3	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.48	22	22	22				44.60	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4497	005	3	1	04	01	H4497_005_3	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.68	40	40	40				51.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	005	3	1	04	01	H4497_005_3	14			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																														
H4497	005	3	1	04	01	H4497_005_3	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	005	4	1	04	01	H4497_005_4	14			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	15.00					0.00	0.00	0.00											6.00	12.00	14.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4497	005	4	1	04	01	H4497_005_4	14			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	20.00					0.00	0.00	0.00											8.00	16.00	19.00				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																														
H4497	005	4	1	04	01	H4497_005_4	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.48	22	22	22				44.60	22	22	22										22	22	22				22	22	22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4497	005	4	1	04	01	H4497_005_4	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											43.68	40	40	40				51.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4497	005	4	1	04	01	H4497_005_4	14			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																														
H4497	005	4	1	04	01	H4497_005_4	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4506	003	0	1	02	01	H4506_003_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4506	003	0	1	02	01	H4506_003_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4506	003	0	1	02	01	H4506_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.93	25	25	25				116.93	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4506	003	0	1	02	01	H4506_003_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											73.72	38	38	38				71.78	37	37	37											38	38					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4506	003	0	1	02	01	H4506_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4506	003	0	1	02	01	H4506_003_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4506	030	0	1	02	01	H4506_030_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4506	030	0	1	02	01	H4506_030_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.67	25	25	25				130.67	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4506	030	0	1	02	01	H4506_030_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.10	34	34	34				65.12	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4506	030	0	1	02	01	H4506_030_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								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		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	026	0	1	01	01	H4513_026_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	026	0	1	01	01	H4513_026_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											60.44	50	50	50				54.61	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											618.71	30						449.98	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	25			25			25			25			25		25
H4513	027	0	1	01	01	H4513_027_0	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	027	0	1	01	01	H4513_027_0	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	027	0	1	01	01	H4513_027_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.22	24	24	24				26.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	027	0	1	01	01	H4513_027_0	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											50.48	25	25	25				54.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	027	0	1	01	01	H4513_027_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											477.91	25						398.52	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	25			25			25			25			25		25
H4513	030	0	1	01	01	H4513_030_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	030	0	1	01	01	H4513_030_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	030	0	1	01	01	H4513_030_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	030	0	1	01	01	H4513_030_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											51.96	50	50	50				54.19	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	030	0	1	01	01	H4513_030_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											609.13	29						459.59	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	034	0	1	01	01	H4513_034_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	034	0	1	01	01	H4513_034_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	034	0	1	01	01	H4513_034_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											22.08	23	23	23				22.47	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4513	034	0	1	01	01	H4513_034_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											46.85	25	25	25				52.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	034	0	1	01	01	H4513_034_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											536.55	25						432.06	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	25			25			25			25			25		25
H4513	036	0	1	02	01	H4513_036_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	036	0	1	02	01	H4513_036_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	036	0	1	02	01	H4513_036_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	036	0	1	02	01	H4513_036_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											65.93	50	50	50				48.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	036	0	1	02	01	H4513_036_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											727.87	30						397.25	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	25			25			25			25			25		25
H4513	037	0	1	01	01	H4513_037_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	037	0	1	01	01	H4513_037_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	037	0	1	01	01	H4513_037_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	037	0	1	01	01	H4513_037_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											61.13	50	50	50				52.51	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	037	0	1	01	01	H4513_037_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											632.27	29						443.90	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	038	0	1	01	01	H4513_038_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	038	0	1	01	01	H4513_038_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	038	0	1	01	01	H4513_038_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	038	0	1	01	01	H4513_038_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											56.65	50	50	50				50.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	038	0	1	01	01	H4513_038_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											645.79	30						594.09	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	039	0	1	01	01	H4513_039_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	039	0	1	01	01	H4513_039_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	039	0	1	01	01	H4513_039_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											19.13	23	23	23				20.69	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4513	039	0	1	01	01	H4513_039_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											44.28	25	25	25				51.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	039	0	1	01	01	H4513_039_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											477.41	25						346.00	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	25			25			25			25			25		25
H4513	046	1	1	01	01	H4513_046_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	046	1	1	01	01	H4513_046_1	5			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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	046	1	1	01	01	H4513_046_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	046	1	1	01	01	H4513_046_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											56.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	046	1	1	01	01	H4513_046_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.17	26						533.18	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	25			25			25			25			25		25
H4513	046	2	1	01	01	H4513_046_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	046	2	1	01	01	H4513_046_2	5			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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	046	2	1	01	01	H4513_046_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	046	2	1	01	01	H4513_046_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											56.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	046	2	1	01	01	H4513_046_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											634.17	26						533.18	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	25			25			25			25			25		25
H4513	049	1	1	01	01	H4513_049_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	049	1	1	01	01	H4513_049_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	049	1	1	01	01	H4513_049_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	1	1	01	01	H4513_049_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											56.47	50	50	50				50.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	1	1	01	01	H4513_049_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.00	30						478.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	049	2	1	01	01	H4513_049_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	049	2	1	01	01	H4513_049_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	049	2	1	01	01	H4513_049_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	2	1	01	01	H4513_049_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											56.47	50	50	50				50.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	2	1	01	01	H4513_049_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.00	30						478.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	049	3	1	01	01	H4513_049_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	049	3	1	01	01	H4513_049_3	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	049	3	1	01	01	H4513_049_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	3	1	01	01	H4513_049_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											56.47	50	50	50				50.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	3	1	01	01	H4513_049_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.00	30						478.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	049	4	1	01	01	H4513_049_4	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	049	4	1	01	01	H4513_049_4	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	049	4	1	01	01	H4513_049_4	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	4	1	01	01	H4513_049_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											56.47	50	50	50				50.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	4	1	01	01	H4513_049_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.00	30						478.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	049	5	1	01	01	H4513_049_5	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	049	5	1	01	01	H4513_049_5	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	049	5	1	01	01	H4513_049_5	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	5	1	01	01	H4513_049_5	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											56.47	50	50	50				50.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	049	5	1	01	01	H4513_049_5	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											703.00	30						478.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	050	0	1	01	01	H4513_050_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	050	0	1	01	01	H4513_050_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	050	0	1	01	01	H4513_050_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	050	0	1	01	01	H4513_050_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											56.31	50	50	50				52.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	050	0	1	01	01	H4513_050_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											644.30	30						485.74	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	25			25			25			25			25		25
H4513	052	0	1	01	01	H4513_052_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	052	0	1	01	01	H4513_052_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	052	0	1	01	01	H4513_052_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	052	0	1	01	01	H4513_052_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											53.63	50	50	50				51.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	052	0	1	01	01	H4513_052_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											677.76	30						487.49	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	25			25			25			25			25		25
H4513	055	0	1	01	01	H4513_055_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	055	0	1	01	01	H4513_055_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	055	0	1	01	01	H4513_055_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											21.64	24	24	24				23.66	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	055	0	1	01	01	H4513_055_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											52.25	25	25	25				52.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	055	0	1	01	01	H4513_055_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.72	25						443.44	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	25			25			25			25			25		25
H4513	060	1	1	01	01	H4513_060_1	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	1	1	01	01	H4513_060_1	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	1	1	01	01	H4513_060_1	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.08	24	24	24				27.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	060	1	1	01	01	H4513_060_1	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											54.12	25	25	25				59.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	060	1	1	01	01	H4513_060_1	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.20	25						409.40	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	25			25			25			25			25		25
H4513	060	2	1	01	01	H4513_060_2	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	2	1	01	01	H4513_060_2	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	2	1	01	01	H4513_060_2	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.08	24	24	24				27.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	060	2	1	01	01	H4513_060_2	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											54.12	25	25	25				59.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	060	2	1	01	01	H4513_060_2	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.20	25						409.40	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	25			25			25			25			25		25
H4513	060	3	1	01	01	H4513_060_3	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	3	1	01	01	H4513_060_3	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	3	1	01	01	H4513_060_3	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.08	24	24	24				27.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	060	3	1	01	01	H4513_060_3	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											54.12	25	25	25				59.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	060	3	1	01	01	H4513_060_3	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.20	25						409.40	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	25			25			25			25			25		25
H4513	060	4	1	01	01	H4513_060_4	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	4	1	01	01	H4513_060_4	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	4	1	01	01	H4513_060_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											24.08	24	24	24				27.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	060	4	1	01	01	H4513_060_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											54.12	25	25	25				59.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	060	4	1	01	01	H4513_060_4	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.20	25						409.40	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	25			25			25			25			25		25
H4513	060	5	1	01	01	H4513_060_5	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	5	1	01	01	H4513_060_5	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	060	5	1	01	01	H4513_060_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											24.08	24	24	24				27.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	060	5	1	01	01	H4513_060_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											54.12	25	25	25				59.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	060	5	1	01	01	H4513_060_5	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											497.20	25						409.40	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	061	1	1	01	01	H4513_061_1	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	061	1	1	01	01	H4513_061_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											73.15	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.04	30						494.58	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	061	2	1	01	01	H4513_061_2	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	061	2	1	01	01	H4513_061_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											73.15	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.04	30						494.58	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	061	3	1	01	01	H4513_061_3	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	061	3	1	01	01	H4513_061_3	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											73.15	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.04	30						494.58	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	061	4	1	01	01	H4513_061_4	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	061	4	1	01	01	H4513_061_4	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											73.15	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.04	30						494.58	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	061	5	1	01	01	H4513_061_5	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	061	5	1	01	01	H4513_061_5	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											73.15	50	50	50				65.82	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.04	30						494.58	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	25			25			25			25			25		25
H4513	063	0	1	01	01	H4513_063_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	063	0	1	01	01	H4513_063_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	063	0	1	01	01	H4513_063_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											20.74	23	23	23				21.61	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4513	063	0	1	01	01	H4513_063_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											46.82	25	25	25				52.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	063	0	1	01	01	H4513_063_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											465.17	25						394.51	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	064	0	1	01	01	H4513_064_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	064	0	1	01	01	H4513_064_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											75.11	50	50	50				62.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											655.31	30						594.13	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	25			25			25			25			25		25
H4513	068	1	1	01	01	H4513_068_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	068	1	1	01	01	H4513_068_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	068	1	1	01	01	H4513_068_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	1	1	01	01	H4513_068_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											64.51	50	50	50				56.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	1	1	01	01	H4513_068_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											738.88	29						503.74	29												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	25			25			25			25			25		25
H4513	068	2	1	01	01	H4513_068_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	068	2	1	01	01	H4513_068_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	068	2	1	01	01	H4513_068_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	2	1	01	01	H4513_068_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											64.51	50	50	50				56.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	2	1	01	01	H4513_068_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											738.88	29						503.74	29												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	25			25			25			25			25		25
H4513	068	3	1	01	01	H4513_068_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	068	3	1	01	01	H4513_068_3	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	068	3	1	01	01	H4513_068_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	3	1	01	01	H4513_068_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											64.51	50	50	50				56.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	068	3	1	01	01	H4513_068_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											738.88	29						503.74	29												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	25			25			25			25			25		25
H4513	073	0	1	01	01	H4513_073_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	073	0	1	01	01	H4513_073_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	073	0	1	01	01	H4513_073_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	073	0	1	01	01	H4513_073_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											70.45	50	50	50				68.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	073	0	1	01	01	H4513_073_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											750.97	30						525.05	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	074	0	1	01	01	H4513_074_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	074	0	1	01	01	H4513_074_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											77.80	50	50	50				68.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											737.93	30						456.09	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	075	0	1	01	01	H4513_075_0	4		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	075	0	1	01	01	H4513_075_0	4		N	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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	075	0	1	01	01	H4513_075_0	4		N	Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											25.23	24	24	24				29.64	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	075	0	1	01	01	H4513_075_0	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											55.48	25	25	25				59.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	075	0	1	01	01	H4513_075_0	4		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											535.87	25						439.26	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	25			25			25			25			25		25
H4513	077	1	1	01	01	H4513_077_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	077	1	1	01	01	H4513_077_1	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	077	1	1	01	01	H4513_077_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	1	1	01	01	H4513_077_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											56.43	50	50	50				49.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	1	1	01	01	H4513_077_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											574.40	30						456.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	077	2	1	01	01	H4513_077_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	077	2	1	01	01	H4513_077_2	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	077	2	1	01	01	H4513_077_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	2	1	01	01	H4513_077_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											56.43	50	50	50				49.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	2	1	01	01	H4513_077_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											574.40	30						456.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	077	3	1	01	01	H4513_077_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	077	3	1	01	01	H4513_077_3	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	077	3	1	01	01	H4513_077_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	3	1	01	01	H4513_077_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											56.43	50	50	50				49.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	3	1	01	01	H4513_077_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											574.40	30						456.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	077	4	1	01	01	H4513_077_4	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	077	4	1	01	01	H4513_077_4	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	077	4	1	01	01	H4513_077_4	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	4	1	01	01	H4513_077_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											56.43	50	50	50				49.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	077	4	1	01	01	H4513_077_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											574.40	30						456.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	079	0	1	01	01	H4513_079_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	079	0	1	01	01	H4513_079_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	079	0	1	01	01	H4513_079_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											21.84	23	23	23				22.76	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H4513	079	0	1	01	01	H4513_079_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											48.79	25	25	25				54.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	079	0	1	01	01	H4513_079_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											508.28	25						426.34	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	25			25			25			25			25		25
H4513	080	0	1	01	01	H4513_080_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	080	0	1	01	01	H4513_080_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	080	0	1	01	01	H4513_080_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											22.16	24	24	24				22.76	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	080	0	1	01	01	H4513_080_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											51.06	25	25	25				54.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	080	0	1	01	01	H4513_080_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											485.57	25						428.34	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	25			25			25			25			25		25
H4513	081	0	1	01	01	H4513_081_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	081	0	1	01	01	H4513_081_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	081	0	1	01	01	H4513_081_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											23.25	24	24	24				23.23	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4513	081	0	1	01	01	H4513_081_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											44.37	25	25	25				53.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	081	0	1	01	01	H4513_081_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											498.91	25						399.27	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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	1	1	01	01	H4513_083_1	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	1	1	01	01	H4513_083_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	2	1	01	01	H4513_083_2	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	2	1	01	01	H4513_083_2	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	3	1	01	01	H4513_083_3	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	3	1	01	01	H4513_083_3	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	4	1	01	01	H4513_083_4	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	4	1	01	01	H4513_083_4	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	5	1	01	01	H4513_083_5	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	5	1	01	01	H4513_083_5	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	6	1	01	01	H4513_083_6	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	6	1	01	01	H4513_083_6	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	083	7	1	01	01	H4513_083_7	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	083	7	1	01	01	H4513_083_7	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											74.58	50	50	50				65.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											604.59	29						504.84	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	084	0	1	02	01	H4513_084_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	084	0	1	02	01	H4513_084_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											65.11	50	50	50				63.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											802.46	30						718.42	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	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	085	0	1	01	01	H4513_085_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	085	0	1	01	01	H4513_085_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											76.46	50	50	50				66.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											737.23	30						599.77	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	086	0	1	01	01	H4513_086_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	086	0	1	01	01	H4513_086_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											81.32	50	50	50				72.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											916.96	30						720.15	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	25			25			25			25			25		25
H4513	087	1	1	01	01	H4513_087_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	087	1	1	01	01	H4513_087_1	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	087	1	1	01	01	H4513_087_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	1	1	01	01	H4513_087_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											54.87	50	50	50				47.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	1	1	01	01	H4513_087_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											512.18	30						466.38	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	087	2	1	01	01	H4513_087_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	087	2	1	01	01	H4513_087_2	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	087	2	1	01	01	H4513_087_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	2	1	01	01	H4513_087_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											54.87	50	50	50				47.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	2	1	01	01	H4513_087_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											512.18	30						466.38	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	087	3	1	01	01	H4513_087_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	087	3	1	01	01	H4513_087_3	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	087	3	1	01	01	H4513_087_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	3	1	01	01	H4513_087_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											54.87	50	50	50				47.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	3	1	01	01	H4513_087_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											512.18	30						466.38	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	087	4	1	01	01	H4513_087_4	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	087	4	1	01	01	H4513_087_4	5			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	087	4	1	01	01	H4513_087_4	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	4	1	01	01	H4513_087_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											54.87	50	50	50				47.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	087	4	1	01	01	H4513_087_4	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											512.18	30						466.38	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4513	088	0	1	01	01	H4513_088_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	088	0	1	01	01	H4513_088_0	5			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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	088	0	1	01	01	H4513_088_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	088	0	1	01	01	H4513_088_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											50.69	50	50	50				47.98	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	088	0	1	01	01	H4513_088_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											546.87	27						418.38	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	25			25			25			25			25		25
H4513	089	0	1	01	01	H4513_089_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	089	0	1	01	01	H4513_089_0	5			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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	089	0	1	01	01	H4513_089_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	089	0	1	01	01	H4513_089_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											58.66	50	50	50				48.72	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	089	0	1	01	01	H4513_089_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											550.07	27						423.42	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	25			25			25			25			25		25
H4513	090	0	1	01	01	H4513_090_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	090	0	1	01	01	H4513_090_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	090	0	1	01	01	H4513_090_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	090	0	1	01	01	H4513_090_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											57.44	50	50	50				48.72	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	090	0	1	01	01	H4513_090_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											665.50	28						437.07	28												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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	091	0	1	01	01	H4513_091_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	091	0	1	01	01	H4513_091_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											74.25	50	50	50				64.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											566.45	27						446.35	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					2.00	4.00	6.00											10.00	20.00	30.00				2.00	4.00	0.00				10.00				10.00			0.33	0.07		0.33	0.07	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	2.00	4.00	6.00	10.00	20.00	30.00	2.00	4.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	092	0	1	01	01	H4513_092_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	092	0	1	01	01	H4513_092_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											74.64	50	50	50				65.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											594.93	29						466.46	29												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	25			25			25			25			25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	093	0	1	01	01	H4513_093_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	093	0	1	01	01	H4513_093_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											73.89	50	50	50				64.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											568.02	27						446.18	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	25			25			25			25			25		25
H4513	094	0	1	01	01	H4513_094_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, 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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	094	0	1	01	01	H4513_094_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, Select Diabetic Drugs	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	094	0	1	01	01	H4513_094_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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	094	0	1	01	01	H4513_094_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											33.22	50	50	50				38.63	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	094	0	1	01	01	H4513_094_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											529.19	30						402.66	30												30						30					30			30								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	25			25			25			25			25		25
H4513	094	0	1	01	01	H4513_094_0	5			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					9.00	18.00	27.00											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	27.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	095	0	1	01	01	H4513_095_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	095	0	1	01	01	H4513_095_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	095	0	1	01	01	H4513_095_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	095	0	1	01	01	H4513_095_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											56.15	50	50	50				64.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	095	0	1	01	01	H4513_095_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											558.12	30						555.66	30												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	25			25			25			25			25		25
H4513	096	0	1	02	01	H4513_096_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	096	0	1	02	01	H4513_096_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	096	0	1	02	01	H4513_096_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	096	0	1	02	01	H4513_096_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											61.35	50	50	50				65.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	096	0	1	02	01	H4513_096_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											559.42	30						607.47	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	25			25			25			25			25		25
H4513	097	0	1	01	01	H4513_097_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, 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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	097	0	1	01	01	H4513_097_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, Select Diabetic Drugs	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H4513	097	0	1	01	01	H4513_097_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	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	097	0	1	01	01	H4513_097_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											46.45	50	50	50				39.45	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	097	0	1	01	01	H4513_097_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											661.56	30						410.24	30												30						30					30			30								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	25			25			25			25			25		25
H4513	097	0	1	01	01	H4513_097_0	5			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					9.00	18.00	27.00											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	27.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	098	0	1	01	01	H4513_098_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, Select Diabetic Drugs	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	098	0	1	01	01	H4513_098_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, 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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H4513	098	0	1	01	01	H4513_098_0	4			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	098	0	1	01	01	H4513_098_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											62.36	50	50	50				66.96	50	50	50										50	50	50				50	50	50			50			50								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4513	098	0	1	01	01	H4513_098_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.74	30						396.61	30												30						30					30			30								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	25			25			25			25			25		25
H4513	098	0	1	01	01	H4513_098_0	4			Select Diabetic Drugs	4	11	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								11.00	22.00	33.00					9.00	18.00	27.00											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	27.00	11.00	22.00	33.00	9.00	18.00	18.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4514	007	0	1	02	01	H4514_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	007	0	1	02	01	H4514_007_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	007	0	1	02	01	H4514_007_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4514	007	0	1	02	01	H4514_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4514	007	0	1	02	01	H4514_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				394.00	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	25						25			25			25		25
H4514	014	0	1	02	01	H4514_014_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	014	0	1	02	01	H4514_014_0	4			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																														
H4514	014	0	1	02	01	H4514_014_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				51.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H4514	014	0	1	02	01	H4514_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				91.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	014	0	1	02	01	H4514_014_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	015	0	1	02	01	H4514_015_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	015	0	1	02	01	H4514_015_0	4			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																														
H4514	015	0	1	02	01	H4514_015_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				69.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	22		22						22				22		22
H4514	015	0	1	02	01	H4514_015_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				79.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	015	0	1	02	01	H4514_015_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				360.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	016	0	1	02	01	H4514_016_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4514	016	0	1	02	01	H4514_016_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	016	0	1	02	01	H4514_016_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H4514	016	0	1	02	01	H4514_016_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	016	0	1	02	01	H4514_016_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				402.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	017	0	1	02	01	H4514_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	017	0	1	02	01	H4514_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	017	0	1	02	01	H4514_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4514	017	0	1	02	01	H4514_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4514	017	0	1	02	01	H4514_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H4514	018	0	1	02	01	H4514_018_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4514	018	0	1	02	01	H4514_018_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	018	0	1	02	01	H4514_018_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H4514	018	0	1	02	01	H4514_018_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	018	0	1	02	01	H4514_018_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	021	0	1	02	01	H4514_021_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4514	021	0	1	02	01	H4514_021_0	4		N	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																														
H4514	021	0	1	02	01	H4514_021_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H4514	021	0	1	02	01	H4514_021_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	021	0	1	02	01	H4514_021_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	022	0	1	02	01	H4514_022_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	022	0	1	02	01	H4514_022_0	4			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																														
H4514	022	0	1	02	01	H4514_022_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H4514	022	0	1	02	01	H4514_022_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				80.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	022	0	1	02	01	H4514_022_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				387.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	023	0	1	02	01	H4514_023_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4514	023	0	1	02	01	H4514_023_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	023	0	1	02	01	H4514_023_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H4514	023	0	1	02	01	H4514_023_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	023	0	1	02	01	H4514_023_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				377.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	024	0	1	02	01	H4514_024_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4514	024	0	1	02	01	H4514_024_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4514	024	0	1	02	01	H4514_024_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H4514	024	0	1	02	01	H4514_024_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4514	024	0	1	02	01	H4514_024_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				384.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	001	0	1	01	01	H4523_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																														
H4523	001	0	1	01	01	H4523_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																														
H4523	001	0	1	01	01	H4523_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											72.51	24	24	24				99.11	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4523	001	0	1	01	01	H4523_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											39.73	25	25	25				45.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	001	0	1	01	01	H4523_001_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											568.11	25						668.58	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	25			25			25			25			25		25
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											68.78	24	24	24				96.79	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.28	25	25	25				45.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											570.94	25						605.86	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	25			25			25			25			25		25
H4523	020	0	1	01	01	H4523_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																														
H4523	020	0	1	01	01	H4523_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																														
H4523	020	0	1	01	01	H4523_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											69.33	25	25	25				96.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	020	0	1	01	01	H4523_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											41.77	26	26	26				44.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	020	0	1	01	01	H4523_020_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											573.76	29						742.48	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											69.18	24	24	24				100.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.25	25	25	25				44.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											548.15	25						566.75	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	25			25			25			25			25		25
H4523	024	0	1	01	01	H4523_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																														
H4523	024	0	1	01	01	H4523_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					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																														
H4523	024	0	1	01	01	H4523_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											79.01	25	25	25				104.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	024	0	1	01	01	H4523_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											46.77	26	26	26				44.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	024	0	1	01	01	H4523_024_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											634.96	29						737.87	29												29						29						29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											62.02	22	22	22				86.03	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											41.69	25	25	25				49.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											611.14	27						743.65	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	25			25			25			25			25		25
H4523	028	0	1	01	01	H4523_028_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	028	0	1	01	01	H4523_028_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	028	0	1	01	01	H4523_028_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				73.14	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	22	22	22				22	22	22				22		22
H4523	028	0	1	01	01	H4523_028_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				37.20	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	25	25	25				25	25	25				25		25
H4523	028	0	1	01	01	H4523_028_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				505.70	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	029	0	1	01	01	H4523_029_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	029	0	1	01	01	H4523_029_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	029	0	1	01	01	H4523_029_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				72.91	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	22	22	22				22	22	22				22		22
H4523	029	0	1	01	01	H4523_029_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				37.63	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4523	029	0	1	01	01	H4523_029_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				507.94	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	030	0	1	01	01	H4523_030_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	030	0	1	01	01	H4523_030_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	030	0	1	01	01	H4523_030_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				71.89	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	22	22	22				22	22	22				22		22
H4523	030	0	1	01	01	H4523_030_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				36.94	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4523	030	0	1	01	01	H4523_030_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				496.41	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											67.02	24	24	24				95.68	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.35	25	25	25				50.11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											579.88	25						700.07	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	25			25			25			25			25		25
H4523	034	0	1	01	01	H4523_034_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	034	0	1	01	01	H4523_034_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	034	0	1	01	01	H4523_034_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				72.43	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	22	22	22				22	22	22				22		22
H4523	034	0	1	01	01	H4523_034_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				35.64	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4523	034	0	1	01	01	H4523_034_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				487.02	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	037	0	1	01	01	H4523_037_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	037	0	1	01	01	H4523_037_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																														
H4523	037	0	1	01	01	H4523_037_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.18	22	22	22				90.15	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4523	037	0	1	01	01	H4523_037_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				48.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	037	0	1	01	01	H4523_037_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.57	25						781.55	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	25			25			25			25			25		25
H4523	038	0	1	01	01	H4523_038_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	038	0	1	01	01	H4523_038_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																														
H4523	038	0	1	01	01	H4523_038_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.18	22	22	22				90.15	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H4523	038	0	1	01	01	H4523_038_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				48.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	038	0	1	01	01	H4523_038_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.57	25						781.55	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	25			25			25			25			25		25
H4523	039	0	1	01	01	H4523_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	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	039	0	1	01	01	H4523_039_0	3			Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	039	0	1	01	01	H4523_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				91.65	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	25	25	25				25	25	25				25		25
H4523	039	0	1	01	01	H4523_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				39.03	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4523	039	0	1	01	01	H4523_039_0	3			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				527.59	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	041	0	1	01	01	H4523_041_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	041	0	1	01	01	H4523_041_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	041	0	1	01	01	H4523_041_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				72.09	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	22	22	22				22	22	22				22		22
H4523	041	0	1	01	01	H4523_041_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				35.33	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	25	25	25				25	25	25				25		25
H4523	041	0	1	01	01	H4523_041_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				467.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	042	0	1	01	01	H4523_042_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	042	0	1	01	01	H4523_042_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	042	0	1	01	01	H4523_042_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.93	24	24	24				93.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4523	042	0	1	01	01	H4523_042_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											41.12	25	25	25				48.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4523	042	0	1	01	01	H4523_042_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											565.13	25						695.77	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	25			25			25			25			25		25
H4523	043	0	1	01	01	H4523_043_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	043	0	1	01	01	H4523_043_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	043	0	1	01	01	H4523_043_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				75.95	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	22	22	22				22	22	22				22		22
H4523	043	0	1	01	01	H4523_043_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				37.20	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	25	25	25				25	25	25				25		25
H4523	043	0	1	01	01	H4523_043_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				498.74	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4523	044	0	1	01	01	H4523_044_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	044	0	1	01	01	H4523_044_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4523	044	0	1	01	01	H4523_044_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				73.40	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	22	22	22				22	22	22				22		22
H4523	044	0	1	01	01	H4523_044_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				35.17	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4523	044	0	1	01	01	H4523_044_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				490.76	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	001	0	1	02	01	H4527_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	001	0	1	02	01	H4527_001_0	4			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																														
H4527	001	0	1	02	01	H4527_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	18		18																				18															18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	18		18						18				18		18
H4527	001	0	1	02	01	H4527_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				90.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	001	0	1	02	01	H4527_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				403.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	002	0	1	02	01	H4527_002_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	002	0	1	02	01	H4527_002_0	4			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																														
H4527	002	0	1	02	01	H4527_002_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H4527	002	0	1	02	01	H4527_002_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				84.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	002	0	1	02	01	H4527_002_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				421.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	003	0	1	02	01	H4527_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4527	003	0	1	02	01	H4527_003_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	003	0	1	02	01	H4527_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H4527	003	0	1	02	01	H4527_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				53.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	003	0	1	02	01	H4527_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				401.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	005	0	1	02	01	H4527_005_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	005	0	1	02	01	H4527_005_0	4			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																														
H4527	005	0	1	02	01	H4527_005_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				39.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H4527	005	0	1	02	01	H4527_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				83.00	38																				38																	38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	005	0	1	02	01	H4527_005_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				417.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	013	0	1	02	01	H4527_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	013	0	1	02	01	H4527_013_0	4			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																														
H4527	013	0	1	02	01	H4527_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H4527	013	0	1	02	01	H4527_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				100.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	013	0	1	02	01	H4527_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				401.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	015	0	1	02	01	H4527_015_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4527	015	0	1	02	01	H4527_015_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	015	0	1	02	01	H4527_015_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	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	25		25						25				25		25
H4527	015	0	1	02	01	H4527_015_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	015	0	1	02	01	H4527_015_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				396.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	037	0	1	02	01	H4527_037_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	037	0	1	02	01	H4527_037_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	037	0	1	02	01	H4527_037_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4527	037	0	1	02	01	H4527_037_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	037	0	1	02	01	H4527_037_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H4527	039	0	1	02	01	H4527_039_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	039	0	1	02	01	H4527_039_0	4			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																														
H4527	039	0	1	02	01	H4527_039_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				72.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H4527	039	0	1	02	01	H4527_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				80.00	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	039	0	1	02	01	H4527_039_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				470.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	040	0	1	02	01	H4527_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	040	0	1	02	01	H4527_040_0	4			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																														
H4527	040	0	1	02	01	H4527_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				68.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	22		22						22				22		22
H4527	040	0	1	02	01	H4527_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				76.00	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	040	0	1	02	01	H4527_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				378.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	041	0	1	02	01	H4527_041_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	041	0	1	02	01	H4527_041_0	4			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																														
H4527	041	0	1	02	01	H4527_041_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				76.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H4527	041	0	1	02	01	H4527_041_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				76.00	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	041	0	1	02	01	H4527_041_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				396.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	042	0	1	02	01	H4527_042_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	042	0	1	02	01	H4527_042_0	4			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																														
H4527	042	0	1	02	01	H4527_042_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				86.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H4527	042	0	1	02	01	H4527_042_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				81.00	43																				43																	43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	042	0	1	02	01	H4527_042_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				424.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	045	0	1	02	01	H4527_045_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	045	0	1	02	01	H4527_045_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	045	0	1	02	01	H4527_045_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H4527	045	0	1	02	01	H4527_045_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	045	0	1	02	01	H4527_045_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				412.00	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	25						25			25			25		25
H4527	048	0	1	02	01	H4527_048_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	048	0	1	02	01	H4527_048_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	048	0	1	02	01	H4527_048_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				49.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H4527	048	0	1	02	01	H4527_048_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	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	25						25			25			25		25
H4527	048	0	1	02	01	H4527_048_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H4527	051	0	1	02	01	H4527_051_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	051	0	1	02	01	H4527_051_0	4			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																														
H4527	051	0	1	02	01	H4527_051_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H4527	051	0	1	02	01	H4527_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				88.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	051	0	1	02	01	H4527_051_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				428.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	052	0	1	02	01	H4527_052_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	052	0	1	02	01	H4527_052_0	4			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																														
H4527	052	0	1	02	01	H4527_052_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H4527	052	0	1	02	01	H4527_052_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	052	0	1	02	01	H4527_052_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				400.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	053	0	1	02	01	H4527_053_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	053	0	1	02	01	H4527_053_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	053	0	1	02	01	H4527_053_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4527	053	0	1	02	01	H4527_053_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	053	0	1	02	01	H4527_053_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H4527	054	0	1	02	01	H4527_054_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4527	054	0	1	02	01	H4527_054_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	054	0	1	02	01	H4527_054_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H4527	054	0	1	02	01	H4527_054_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				54.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	054	0	1	02	01	H4527_054_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				384.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	055	0	1	02	01	H4527_055_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	055	0	1	02	01	H4527_055_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	055	0	1	02	01	H4527_055_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				51.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H4527	055	0	1	02	01	H4527_055_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				99.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	055	0	1	02	01	H4527_055_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H4527	056	0	1	02	01	H4527_056_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	056	0	1	02	01	H4527_056_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	056	0	1	02	01	H4527_056_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4527	056	0	1	02	01	H4527_056_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	056	0	1	02	01	H4527_056_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H4527	057	0	1	02	01	H4527_057_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4527	057	0	1	02	01	H4527_057_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	057	0	1	02	01	H4527_057_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H4527	057	0	1	02	01	H4527_057_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				55.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	057	0	1	02	01	H4527_057_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				371.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	058	0	1	02	01	H4527_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	058	0	1	02	01	H4527_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	058	0	1	02	01	H4527_058_0	6			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H4527	058	0	1	02	01	H4527_058_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				95.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	058	0	1	02	01	H4527_058_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				396.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4527	059	0	1	02	01	H4527_059_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	059	0	1	02	01	H4527_059_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4527	059	0	1	02	01	H4527_059_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4527	059	0	1	02	01	H4527_059_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4527	059	0	1	02	01	H4527_059_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				397.00	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	25						25			25			25		25
H4537	001	0	1	04	01	H4537_001_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4537	001	0	1	04	01	H4537_001_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4537	001	0	1	04	01	H4537_001_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											121.27	25	25	25				121.27	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4537	001	0	1	04	01	H4537_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											63.52	36	36	36				63.52	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4537	001	0	1	04	01	H4537_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4537	001	0	1	04	01	H4537_001_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4537	004	0	1	04	01	H4537_004_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4537	004	0	1	04	01	H4537_004_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4537	004	0	1	04	01	H4537_004_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.57	20	20	20				75.57	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H4537	004	0	1	04	01	H4537_004_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4537	004	0	1	04	01	H4537_004_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4537	004	0	1	04	01	H4537_004_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4544	001	0	1	04	01	H4544_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4544	001	0	1	04	01	H4544_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4544	001	0	1	04	01	H4544_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4544	001	0	1	04	01	H4544_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				336.00	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	25						25			25			25		25
H4604	003	0	1	02	01	H4604_003_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	003	0	1	02	01	H4604_003_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	003	0	1	02	01	H4604_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4604	003	0	1	02	01	H4604_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	003	0	1	02	01	H4604_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				411.00	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	25						25			25			25		25
H4604	011	0	1	02	01	H4604_011_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	011	0	1	02	01	H4604_011_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	011	0	1	02	01	H4604_011_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4604	011	0	1	02	01	H4604_011_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	011	0	1	02	01	H4604_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	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	25						25			25			25		25
H4604	012	0	1	02	01	H4604_012_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	012	0	1	02	01	H4604_012_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	012	0	1	02	01	H4604_012_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4604	012	0	1	02	01	H4604_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				85.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	012	0	1	02	01	H4604_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H4604	013	0	1	02	01	H4604_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	013	0	1	02	01	H4604_013_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	013	0	1	02	01	H4604_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4604	013	0	1	02	01	H4604_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				77.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	013	0	1	02	01	H4604_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				53.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H4604	014	0	1	02	01	H4604_014_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				335.00	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	25						25			25			25		25
H4604	016	0	1	02	01	H4604_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	016	0	1	02	01	H4604_016_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	016	0	1	02	01	H4604_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4604	016	0	1	02	01	H4604_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				92.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	016	0	1	02	01	H4604_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				357.00	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	25						25			25			25		25
H4604	017	0	1	02	01	H4604_017_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	017	0	1	02	01	H4604_017_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	017	0	1	02	01	H4604_017_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				60.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H4604	017	0	1	02	01	H4604_017_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	017	0	1	02	01	H4604_017_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				408.00	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	25						25			25			25		25
H4604	018	0	1	02	01	H4604_018_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	018	0	1	02	01	H4604_018_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	018	0	1	02	01	H4604_018_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4604	018	0	1	02	01	H4604_018_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	018	0	1	02	01	H4604_018_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H4604	020	0	1	02	01	H4604_020_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	020	0	1	02	01	H4604_020_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	020	0	1	02	01	H4604_020_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H4604	020	0	1	02	01	H4604_020_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	020	0	1	02	01	H4604_020_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H4604	022	0	1	02	01	H4604_022_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	022	0	1	02	01	H4604_022_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	022	0	1	02	01	H4604_022_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				52.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H4604	022	0	1	02	01	H4604_022_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	022	0	1	02	01	H4604_022_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				333.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	024	0	1	02	01	H4604_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																														
H4604	024	0	1	02	01	H4604_024_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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	024	0	1	02	01	H4604_024_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H4604	024	0	1	02	01	H4604_024_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	024	0	1	02	01	H4604_024_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				414.00	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	25						25			25			25		25
H4604	025	0	1	02	01	H4604_025_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	025	0	1	02	01	H4604_025_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	025	0	1	02	01	H4604_025_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H4604	025	0	1	02	01	H4604_025_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H4604	025	0	1	02	01	H4604_025_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				413.00	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	25						25			25			25		25
H4604	026	0	1	02	01	H4604_026_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4604	026	0	1	02	01	H4604_026_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	026	0	1	02	01	H4604_026_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H4604	026	0	1	02	01	H4604_026_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H4604	026	0	1	02	01	H4604_026_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				352.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4604	027	0	1	02	01	H4604_027_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	027	0	1	02	01	H4604_027_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	027	0	1	02	01	H4604_027_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H4604	027	0	1	02	01	H4604_027_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	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	25						25			25			25		25
H4604	027	0	1	02	01	H4604_027_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				388.00	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	25						25			25			25		25
H4604	028	0	1	02	01	H4604_028_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	028	0	1	02	01	H4604_028_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4604	028	0	1	02	01	H4604_028_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H4604	028	0	1	02	01	H4604_028_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	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	25						25			25			25		25
H4604	028	0	1	02	01	H4604_028_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				415.00	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	25						25			25			25		25
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								10.00	20.00	20.00					5.00	10.00	10.00											10.00	20.00	20.00				5.00	10.00	0.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	20.00	5.00	10.00	10.00	10.00	20.00	20.00	5.00	10.00	0.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											25.74	22	22	22				25.74	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	22	22	22	19	19	19	22	22	22	19	19	19	22		22
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											54.66	38	38	38				54.66	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											645.38	25						645.38	25												25						25					25			25								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								4.00	8.00	8.00					2.00	4.00	4.00											4.00	8.00	8.00				2.00	4.00	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	8.00	8.00	2.00	4.00	4.00	4.00	8.00	8.00	2.00	4.00	0.00	4.00		4.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											29.90	23	23	23				29.90	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	23	23	23	20	20	20	23	23	23	20	20	20	23		23
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											68.69	40	40	40				68.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											856.75	30						856.75	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4610	001	0	1	01	01	H4610_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H4610	001	0	1	01	01	H4610_001_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4610	001	0	1	01	01	H4610_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				40.00	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	25		25						25				25		25
H4610	001	0	1	01	01	H4610_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4610	001	0	1	01	01	H4610_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				343.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4623	001	0	1	02	01	H4623_001_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	0		0				25		25	0		0	0		0
H4623	001	0	1	02	01	H4623_001_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H4623	001	0	1	02	01	H4623_001_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	25		25				25		25	25		25	25		25
H4623	001	0	1	02	01	H4623_001_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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	25		25				25		25	25		25	25		25
H4623	001	0	1	02	01	H4623_001_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	25						25			25			25		25
H4623	002	0	1	02	01	H4623_002_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	0		0				25		25	0		0	0		0
H4623	002	0	1	02	01	H4623_002_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	0		0				25		25	0		0	0		0
H4623	002	0	1	02	01	H4623_002_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	25		25				25		25	25		25	25		25
H4623	002	0	1	02	01	H4623_002_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	25		25				25		25	25		25	25		25
H4623	002	0	1	02	01	H4623_002_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	25						25			25			25		25
H4624	001	0	1	01	01	H4624_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	0	0	0				0	0	0				0		0
H4624	001	0	1	01	01	H4624_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																			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	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	0	0	0				0	0	0				0		0
H4624	001	0	1	01	01	H4624_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				67.34	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	001	0	1	01	01	H4624_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				995.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	003	0	1	01	01	H4624_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	0	0	0				0	0	0				0		0
H4624	003	0	1	01	01	H4624_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																			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	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	0	0	0				0	0	0				0		0
H4624	003	0	1	01	01	H4624_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				66.25	25	25	25																		25	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	25	25	25				25	25	25				25		25
H4624	003	0	1	01	01	H4624_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1096.09	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				65.63	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	25	25	25				25	25	25				25		25
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				1043.85	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				134.17	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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				1211.67	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	0						0						0		0
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	0	0	0				0	0	0				0		0
H4624	011	0	1	01	01	H4624_011_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	011	0	1	01	01	H4624_011_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	011	0	1	01	01	H4624_011_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	011	0	1	01	01	H4624_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				105.33	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	011	0	1	01	01	H4624_011_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				993.33	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						0						0		0
H4624	011	0	1	01	01	H4624_011_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	012	0	1	01	01	H4624_012_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	012	0	1	01	01	H4624_012_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	012	0	1	01	01	H4624_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	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	0	0	0				0	0	0				0		0
H4624	012	0	1	01	01	H4624_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				119.86	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	25	25	25				25	25	25				25		25
H4624	012	0	1	01	01	H4624_012_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				959.17	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						0						0		0
H4624	012	0	1	01	01	H4624_012_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	0	0	0				0	0	0				0		0
H4624	022	0	1	01	01	H4624_022_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	0	0	0				0	0	0				0		0
H4624	022	0	1	01	01	H4624_022_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	022	0	1	01	01	H4624_022_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	0	0	0				0	0	0				0		0
H4624	022	0	1	01	01	H4624_022_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				66.78	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	022	0	1	01	01	H4624_022_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1101.54	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	023	0	1	01	01	H4624_023_0	8			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	023	0	1	01	01	H4624_023_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	023	0	1	01	01	H4624_023_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	023	0	1	01	01	H4624_023_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				129.22	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H4624	023	0	1	01	01	H4624_023_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				834.70	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						0						0		0
H4624	023	0	1	01	01	H4624_023_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	025	0	1	01	01	H4624_025_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	0	0	0				0	0	0				0		0
H4624	025	0	1	01	01	H4624_025_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	025	0	1	01	01	H4624_025_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	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	0	0	0				0	0	0				0		0
H4624	025	0	1	01	01	H4624_025_0	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				131.53	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	025	0	1	01	01	H4624_025_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				883.23	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						0						0		0
H4624	025	0	1	01	01	H4624_025_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	026	0	1	01	01	H4624_026_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	026	0	1	01	01	H4624_026_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																														
H4624	026	0	1	01	01	H4624_026_0	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	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	0	0	0				0	0	0				0		0
H4624	026	0	1	01	01	H4624_026_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				70.02	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	026	0	1	01	01	H4624_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1188.60	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	027	0	1	01	01	H4624_027_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	0	0	0				0	0	0				0		0
H4624	027	0	1	01	01	H4624_027_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	027	0	1	01	01	H4624_027_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	0	0	0				0	0	0				0		0
H4624	027	0	1	01	01	H4624_027_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				122.89	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H4624	027	0	1	01	01	H4624_027_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				967.98	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						0						0		0
H4624	027	0	1	01	01	H4624_027_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	0	0	0				0	0	0				0		0
H4624	028	0	1	01	01	H4624_028_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	0	0	0				0	0	0				0		0
H4624	028	0	1	01	01	H4624_028_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	028	0	1	01	01	H4624_028_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	0	0	0				0	0	0				0		0
H4624	028	0	1	01	01	H4624_028_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				116.12	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	028	0	1	01	01	H4624_028_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1116.23	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						0						0		0
H4624	028	0	1	01	01	H4624_028_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	0	0	0				0	0	0				0		0
H4624	029	0	1	01	01	H4624_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	029	0	1	01	01	H4624_029_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	029	0	1	01	01	H4624_029_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	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	0	0	0				0	0	0				0		0
H4624	029	0	1	01	01	H4624_029_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				124.69	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	029	0	1	01	01	H4624_029_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				952.13	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						0						0		0
H4624	029	0	1	01	01	H4624_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	031	0	1	01	01	H4624_031_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	0	0	0				0	0	0				0		0
H4624	031	0	1	01	01	H4624_031_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	031	0	1	01	01	H4624_031_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	0	0	0				0	0	0				0		0
H4624	031	0	1	01	01	H4624_031_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				130.51	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	031	0	1	01	01	H4624_031_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				900.10	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						0						0		0
H4624	031	0	1	01	01	H4624_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	032	0	1	01	01	H4624_032_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4624	032	0	1	01	01	H4624_032_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	032	0	1	01	01	H4624_032_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	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	0	0	0				0	0	0				0		0
H4624	032	0	1	01	01	H4624_032_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				129.51	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	032	0	1	01	01	H4624_032_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				891.17	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						0						0		0
H4624	032	0	1	01	01	H4624_032_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	0	0	0				0	0	0				0		0
H4624	033	0	1	01	01	H4624_033_0	7			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	033	0	1	01	01	H4624_033_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	033	0	1	01	01	H4624_033_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	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	0	0	0				0	0	0				0		0
H4624	033	0	1	01	01	H4624_033_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				132.82	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	033	0	1	01	01	H4624_033_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				892.78	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						0						0		0
H4624	033	0	1	01	01	H4624_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	034	0	1	01	01	H4624_034_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	0	0	0				0	0	0				0		0
H4624	034	0	1	01	01	H4624_034_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	034	0	1	01	01	H4624_034_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	0	0	0				0	0	0				0		0
H4624	034	0	1	01	01	H4624_034_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				128.38	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H4624	034	0	1	01	01	H4624_034_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				805.42	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						0						0		0
H4624	034	0	1	01	01	H4624_034_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	0	0	0				0	0	0				0		0
H4624	036	0	1	01	01	H4624_036_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	0	0	0				0	0	0				0		0
H4624	036	0	1	01	01	H4624_036_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	036	0	1	01	01	H4624_036_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	0	0	0				0	0	0				0		0
H4624	036	0	1	01	01	H4624_036_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				130.76	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	036	0	1	01	01	H4624_036_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1031.50	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						0						0		0
H4624	036	0	1	01	01	H4624_036_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	0	0	0				0	0	0				0		0
H4624	037	0	1	01	01	H4624_037_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	0	0	0				0	0	0				0		0
H4624	037	0	1	01	01	H4624_037_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	037	0	1	01	01	H4624_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																			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	0	0	0				0	0	0				0		0
H4624	037	0	1	01	01	H4624_037_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.51	25	25	25																		25	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	25	25	25				25	25	25				25		25
H4624	037	0	1	01	01	H4624_037_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1090.53	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	038	0	1	01	01	H4624_038_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	0	0	0				0	0	0				0		0
H4624	038	0	1	01	01	H4624_038_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																														
H4624	038	0	1	01	01	H4624_038_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			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	0	0	0				0	0	0				0		0
H4624	038	0	1	01	01	H4624_038_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				77.76	25	25	25																		25	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	25	25	25				25	25	25				25		25
H4624	038	0	1	01	01	H4624_038_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1094.21	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	039	0	1	01	01	H4624_039_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	0	0	0				0	0	0				0		0
H4624	039	0	1	01	01	H4624_039_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	039	0	1	01	01	H4624_039_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			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	0	0	0				0	0	0				0		0
H4624	039	0	1	01	01	H4624_039_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				130.42	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	039	0	1	01	01	H4624_039_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1094.21	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						0						0		0
H4624	039	0	1	01	01	H4624_039_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	040	0	1	01	01	H4624_040_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	0	0	0				0	0	0				0		0
H4624	040	0	1	01	01	H4624_040_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	040	0	1	01	01	H4624_040_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	0	0	0				0	0	0				0		0
H4624	040	0	1	01	01	H4624_040_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				130.71	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	040	0	1	01	01	H4624_040_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				878.19	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						0						0		0
H4624	040	0	1	01	01	H4624_040_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	042	0	1	01	01	H4624_042_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	0	0	0				0	0	0				0		0
H4624	042	0	1	01	01	H4624_042_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	042	0	1	01	01	H4624_042_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			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	0	0	0				0	0	0				0		0
H4624	042	0	1	01	01	H4624_042_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	31	60	100				30		31				127.24	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	042	0	1	01	01	H4624_042_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				988.92	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						0						0		0
H4624	042	0	1	01	01	H4624_042_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H4624	043	0	1	01	01	H4624_043_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	0	0	0				0	0	0				0		0
H4624	043	0	1	01	01	H4624_043_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	043	0	1	01	01	H4624_043_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	0	0	0				0	0	0				0		0
H4624	043	0	1	01	01	H4624_043_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				82.62	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	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	043	0	1	01	01	H4624_043_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1204.39	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	044	0	1	01	01	H4624_044_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	0	0	0				0	0	0				0		0
H4624	044	0	1	01	01	H4624_044_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	044	0	1	01	01	H4624_044_0	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			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	0	0	0				0	0	0				0		0
H4624	044	0	1	01	01	H4624_044_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				79.69	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	25	25	25				25	25	25				25		25
H4624	044	0	1	01	01	H4624_044_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1137.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H4624	045	0	1	01	01	H4624_045_0	7			Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				1.42	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	70.00				35.00		35.00	15	15	15				15	15	15				15		15
H4624	045	0	1	01	01	H4624_045_0	7			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				10.09	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4624	045	0	1	01	01	H4624_045_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				116.22	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	045	0	1	01	01	H4624_045_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				67.58	25	25	25																		25	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	25	25	25				25	25	25				25		25
H4624	045	0	1	01	01	H4624_045_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				948.74	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4624	046	0	1	01	01	H4624_046_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	0	0	0				0	0	0				0		0
H4624	046	0	1	01	01	H4624_046_0	8			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4624	046	0	1	01	01	H4624_046_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	0	0	0				0	0	0				0		0
H4624	046	0	1	01	01	H4624_046_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				130.65	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H4624	046	0	1	01	01	H4624_046_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1080.15	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						0						0		0
H4624	046	0	1	01	01	H4624_046_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	11.00	22.00	33.00																			11.00	22.00	33.00																11.00				11.00		0.37			0.37			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4647	001	0	1	01	01	H4647_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4647	001	0	1	01	01	H4647_001_0	5			Generic	4	11	3	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	0	0	0				0	0	0				0		0
H4647	001	0	1	01	01	H4647_001_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	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	25	25	25				25	25	25				25		25
H4647	001	0	1	01	01	H4647_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				75.91	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	25	25	25				25	25	25				25		25
H4647	001	0	1	01	01	H4647_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				666.55	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4647	002	0	1	01	01	H4647_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H4647	002	0	1	01	01	H4647_002_0	5			Generic	4	11	3	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	0	0	0				0	0	0				0		0
H4647	002	0	1	01	01	H4647_002_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	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	25	25	25				25	25	25				25		25
H4647	002	0	1	01	01	H4647_002_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				66.38	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	25	25	25				25	25	25				25		25
H4647	002	0	1	01	01	H4647_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				606.80	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4661	001	0	1	02	01	H4661_001_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4661	001	0	1	02	01	H4661_001_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4661	001	0	1	02	01	H4661_001_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											128.54	25	25	25				128.54	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4661	001	0	1	02	01	H4661_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											66.63	34	34	34				64.67	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4661	001	0	1	02	01	H4661_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	001	0	1	02	01	H4661_001_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	003	0	1	02	01	H4661_003_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	003	0	1	02	01	H4661_003_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	003	0	1	02	01	H4661_003_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.01	20	20	20				74.01	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H4661	003	0	1	02	01	H4661_003_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4661	003	0	1	02	01	H4661_003_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	003	0	1	02	01	H4661_003_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	005	0	1	02	01	H4661_005_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	005	0	1	02	01	H4661_005_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	005	0	1	02	01	H4661_005_0	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.91	25	25	25				97.91	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4661	005	0	1	02	01	H4661_005_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4661	005	0	1	02	01	H4661_005_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4661	005	0	1	02	01	H4661_005_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								4.00	8.00	12.00					0.00	0.00	0.00												8.00	12.00					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																														
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 Drug, 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 Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	5.00	10.00	15.00							20.00		20.00	25	25	25	25	25	25							25		25
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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	25.00	50.00	75.00							25.00		25.00	25	25	25	25	25	25							25		25
H4676	001	0	1	01	01	H4676_001_0	7			Non-Preferred Drug	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 Drug, Specialty Tier, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00							35.00		35.00	25	25	25	25	25	25							25		25
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											647.95	33	33	33				570.91	33	33	33																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, 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 Drug, 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				6.03	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
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				87.23	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H4676	002	0	1	01	01	H4676_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01			1	30	60	90				2	1							30		31				68.77	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
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				409.83	25	25	25																																			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, 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 Drug, Specialty Tier, Vaccines																														
H4694	001	0	1	01	01	H4694_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H4694	001	0	1	01	01	H4694_001_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	001	0	1	01	01	H4694_001_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				79.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	001	0	1	01	01	H4694_001_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				34.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	001	0	1	01	01	H4694_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	001	0	1	01	01	H4694_001_0	6		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																														
H4694	002	0	1	01	01	H4694_002_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	002	0	1	01	01	H4694_002_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	002	0	1	01	01	H4694_002_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				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	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	002	0	1	01	01	H4694_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				26.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	002	0	1	01	01	H4694_002_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	002	0	1	01	01	H4694_002_0	6		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																														
H4694	003	0	1	01	01	H4694_003_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H4694	003	0	1	01	01	H4694_003_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	003	0	1	01	01	H4694_003_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				80.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	003	0	1	01	01	H4694_003_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				32.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	003	0	1	01	01	H4694_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	003	0	1	01	01	H4694_003_0	6		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																														
H4694	004	0	1	01	01	H4694_004_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	004	0	1	01	01	H4694_004_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	004	0	1	01	01	H4694_004_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				73.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	004	0	1	01	01	H4694_004_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				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4694	004	0	1	01	01	H4694_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4694	004	0	1	01	01	H4694_004_0	6		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																														
H4704	001	0	1	04	01	H4704_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H4704	001	0	1	04	01	H4704_001_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, Select Care Drugs																														
H4704	001	0	1	04	01	H4704_001_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				77.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4704	001	0	1	04	01	H4704_001_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				33.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4704	001	0	1	04	01	H4704_001_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																														
H4704	001	0	1	04	01	H4704_001_0	6		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																														
H4704	002	0	1	04	01	H4704_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		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																														
H4704	002	0	1	04	01	H4704_002_0	5		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, Select Care Drugs																														
H4704	002	0	1	04	01	H4704_002_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				66.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4704	002	0	1	04	01	H4704_002_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4704	002	0	1	04	01	H4704_002_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4704	002	0	1	04	01	H4704_002_0	5		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																														
H4711	001	0	1	01	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	01	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	01	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											70.94	24	24	24				96.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4711	001	0	1	01	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											42.04	25	25	25				44.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4711	001	0	1	01	01	H4711_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											535.16	25						647.39	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	25			25			25			25			25		25
H4711	002	0	1	01	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	01	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	01	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											68.31	24	24	24				94.35	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4711	002	0	1	01	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											43.63	25	25	25				46.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4711	002	0	1	01	01	H4711_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											543.06	25						670.98	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	25			25			25			25			25		25
H4711	005	0	1	01	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	01	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	01	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											70.68	24	24	24				95.28	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4711	005	0	1	01	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											40.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4711	005	0	1	01	01	H4711_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											557.23	25						623.23	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	25			25			25			25			25		25
H4711	008	0	1	02	01	H4711_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																														
H4711	008	0	1	02	01	H4711_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																														
H4711	008	0	1	02	01	H4711_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											69.05	24	24	24				96.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4711	008	0	1	02	01	H4711_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											40.13	25	25	25				50.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4711	008	0	1	02	01	H4711_008_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											605.83	25						686.46	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	25			25			25			25			25		25
H4711	011	0	1	01	01	H4711_011_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	011	0	1	01	01	H4711_011_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	011	0	1	01	01	H4711_011_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				74.16	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	22	22	22				22	22	22				22		22
H4711	011	0	1	01	01	H4711_011_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				40.25	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4711	011	0	1	01	01	H4711_011_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				490.58	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4711	012	0	1	01	01	H4711_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	012	0	1	01	01	H4711_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	012	0	1	01	01	H4711_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.57	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	22	22	22				22	22	22				22		22
H4711	012	0	1	01	01	H4711_012_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4711	012	0	1	01	01	H4711_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				490.73	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4711	013	0	1	01	01	H4711_013_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	013	0	1	01	01	H4711_013_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4711	013	0	1	01	01	H4711_013_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.22	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		35.00	22	22	22				22	22	22				22		22
H4711	013	0	1	01	01	H4711_013_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				37.75	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H4711	013	0	1	01	01	H4711_013_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				494.78	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Preferred Generic	2	01	1	1	1	1	111		01	100		1	31	62	93				2	2			93				31		31				2.26	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						105.00				35.00		35.00	25	25	25						25				25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Generic	2	01	1	1	2	1	111		01	100		1	31	62	93				2	2			93				31		31				11.76	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						105.00				35.00		35.00	25	25	25						25				25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Preferred Brand	2	10	1	1	3	1	111		01	100		1	31	62	93				2	2			93				31		31				92.96	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						105.00				35.00		35.00	25	25	25						25				25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Non-Preferred Brand	2	10	1	1	4	1	111		01	100		1	31	62	93				2	2			93				31		31				79.39	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						105.00				35.00		35.00	25	25	25						25				25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	31								31						31		31				483.67	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H4733	001	0	1	01	01	H4733_001_0	5		N	Select Care Drugs	2	01	1	1	6	1	111		01	100		1	31	62	100				2	2			100				31		31				0.74	15	15	15																				15															15			15								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	15	15	15						15				15		15
H4739	001	0	1	01	01	H4739_001_0	5		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				4.21	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4739	001	0	1	01	01	H4739_001_0	5		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				15.07	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4739	001	0	1	01	01	H4739_001_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				94.06	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4739	001	0	1	01	01	H4739_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				21.03	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H4739	001	0	1	01	01	H4739_001_0	5		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				573.00	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4739	001	0	1	01	01	H4739_001_0	5		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	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	6.00	12.00	18.00																			6.00	6.00	6.00																6.00				6.00		0.20			0.20			0.19	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	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				68.73	20	20	20																		15	15	15															20			20								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	20	20	20				15	15	15				20		20
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				32.91	25	25	25																		25	25	25															25			25								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				66.22	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H4808	001	0	1	04	01	H4808_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	0	0	0				0	0	0				0		0
H4808	001	0	1	04	01	H4808_001_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																			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	25	25	25				25	25	25				25		25
H4808	001	0	1	04	01	H4808_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				58.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H4808	001	0	1	04	01	H4808_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				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	25	25	25				25	25	25				25		25
H4808	001	0	1	04	01	H4808_001_0	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	25						25						25		25
H4808	002	0	1	04	01	H4808_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	0	0	0				0	0	0				0		0
H4808	002	0	1	04	01	H4808_002_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4808	002	0	1	04	01	H4808_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				61.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H4808	002	0	1	04	01	H4808_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				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	25	25	25				25	25	25				25		25
H4808	002	0	1	04	01	H4808_002_0	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	25						25						25		25
H4808	003	0	1	04	01	H4808_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	0	0	0				0	0	0				0		0
H4808	003	0	1	04	01	H4808_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	25	25	25				25	25	25				25		25
H4808	003	0	1	04	01	H4808_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				65.00	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	22	22	22				22	22	22				22		22
H4808	003	0	1	04	01	H4808_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				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	25	25	25				25	25	25				25		25
H4808	003	0	1	04	01	H4808_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	25						25						25		25
H4808	005	0	1	04	01	H4808_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H4808	005	0	1	04	01	H4808_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4808	005	0	1	04	01	H4808_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				33.00	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	19	19	19				19	19	19				19		19
H4808	005	0	1	04	01	H4808_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				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	25	25	25				25	25	25				25		25
H4808	005	0	1	04	01	H4808_005_0	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	25						25						25		25
H4835	001	0	1	01	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	01	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	01	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											69.09	24	24	24				97.11	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4835	001	0	1	01	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											42.94	25	25	25				47.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4835	001	0	1	01	01	H4835_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											579.49	25						652.92	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	25			25			25			25			25		25
H4835	002	0	1	01	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	01	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	01	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											66.78	24	24	24				95.66	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4835	002	0	1	01	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											43.83	25	25	25				45.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4835	002	0	1	01	01	H4835_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											589.76	25						710.68	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	25			25			25			25			25		25
H4847	001	0	1	02	01	H4847_001_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4847	001	0	1	02	01	H4847_001_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4847	001	0	1	02	01	H4847_001_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.29	25	25	25				123.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4847	001	0	1	02	01	H4847_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											66.80	35	35	35				64.89	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4847	001	0	1	02	01	H4847_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4847	001	0	1	02	01	H4847_001_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4847	005	0	1	02	01	H4847_005_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											88.66	21	21	21				88.66	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H4847	005	0	1	02	01	H4847_005_0	9			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4847	005	0	1	02	01	H4847_005_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4847	007	0	1	02	01	H4847_007_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4847	007	0	1	02	01	H4847_007_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4847	007	0	1	02	01	H4847_007_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.56	25	25	25				119.56	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4847	007	0	1	02	01	H4847_007_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											62.62	36	36	36				60.88	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4847	007	0	1	02	01	H4847_007_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4847	007	0	1	02	01	H4847_007_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	004	0	1	01	01	H4868_004_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	004	0	1	01	01	H4868_004_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	004	0	1	01	01	H4868_004_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											87.25	20	20	20				87.25	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H4868	004	0	1	01	01	H4868_004_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	004	0	1	01	01	H4868_004_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	004	0	1	01	01	H4868_004_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	014	0	1	01	01	H4868_014_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	014	0	1	01	01	H4868_014_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	014	0	1	01	01	H4868_014_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.05	25	25	25				93.05	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	014	0	1	01	01	H4868_014_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	014	0	1	01	01	H4868_014_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	014	0	1	01	01	H4868_014_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	016	0	1	02	01	H4868_016_0	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	016	0	1	02	01	H4868_016_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											95.99	25	25	25				95.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	016	0	1	02	01	H4868_016_0	9			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	016	0	1	02	01	H4868_016_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	019	0	1	02	01	H4868_019_0	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H4868	019	0	1	02	01	H4868_019_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H4868	019	0	1	02	01	H4868_019_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											104.72	25	25	25				104.72	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	019	0	1	02	01	H4868_019_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.81	33	33	33				97.81	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H4868	019	0	1	02	01	H4868_019_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4868	019	0	1	02	01	H4868_019_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H4869	001	0	1	02	01	H4869_001_0	4			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																														
H4869	001	0	1	02	01	H4869_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	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	4			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	250.00																			100.00	200.00	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	25	25	25				25	25	25				25		25
H4869	001	0	1	02	01	H4869_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				419.78	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	4			Select Diabetic 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 Brand, Specialty Tier, Select Diabetic Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4869	003	0	1	02	01	H4869_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H4869	003	0	1	02	01	H4869_003_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	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	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	117.00																			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	5			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	250.00																			100.00	200.00	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	25	25	25				25	25	25				25		25
H4869	003	0	1	02	01	H4869_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				285.07	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	5			Select Diabetic 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 Brand, Specialty Tier, Select Diabetic Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4869	011	0	1	02	01	H4869_011_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H4869	011	0	1	02	01	H4869_011_0	4			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																														
H4869	011	0	1	02	01	H4869_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	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	4			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	250.00																			100.00	200.00	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	25	25	25				25	25	25				25		25
H4869	011	0	1	02	01	H4869_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				412.29	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	4			Select Diabetic 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 Brand, Specialty Tier, Select Diabetic Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4869	013	0	1	02	01	H4869_013_0	5			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Diabetic Drugs																														
H4869	013	0	1	02	01	H4869_013_0	5			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	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	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	117.00																			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	5			Non-Preferred Brand	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	100.00	200.00	250.00																			100.00	200.00	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	25	25	25				25	25	25				25		25
H4869	013	0	1	02	01	H4869_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				336.20	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	5			Select Diabetic 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 Brand, Specialty Tier, Select Diabetic Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H4875	016	1	1	04	01	H4875_016_1	6			Preferred Generic	4	01	1	2	1	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	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	016	1	1	04	01	H4875_016_1	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.98	25	25	25				60.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	1	1	04	01	H4875_016_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.33	37	37	37				13.24	32	32	32										37	37	37				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	1	1	04	01	H4875_016_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	016	2	1	04	01	H4875_016_2	6			Preferred Generic	4	01	1	2	1	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	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	016	2	1	04	01	H4875_016_2	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.98	25	25	25				60.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	2	1	04	01	H4875_016_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.33	37	37	37				13.24	32	32	32										37	37	37				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	2	1	04	01	H4875_016_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	016	3	1	04	01	H4875_016_3	6			Preferred Generic	4	01	1	2	1	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	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	016	3	1	04	01	H4875_016_3	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.98	25	25	25				60.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	3	1	04	01	H4875_016_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.33	37	37	37				13.24	32	32	32										37	37	37				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	3	1	04	01	H4875_016_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	016	4	1	04	01	H4875_016_4	6			Preferred Generic	4	01	1	2	1	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	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	016	4	1	04	01	H4875_016_4	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.98	25	25	25				60.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	4	1	04	01	H4875_016_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.33	37	37	37				13.24	32	32	32										37	37	37				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	4	1	04	01	H4875_016_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	016	5	1	04	01	H4875_016_5	6			Preferred Generic	4	01	1	2	1	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	0.00											7.00	14.00	21.00				2.00	4.00	0.00				7.00				7.00			0.23	0.07		0.23	0.07	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	016	5	1	04	01	H4875_016_5	6			Generic	4	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					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	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											57.98	25	25	25				60.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	5	1	04	01	H4875_016_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											17.33	37	37	37				13.24	32	32	32										37	37	37				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4875	016	5	1	04	01	H4875_016_5	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1.00	33						1.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	018	1	1	04	01	H4875_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								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	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								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	018	1	1	04	01	H4875_018_1	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.52	25	25	25				58.57	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											25.24	40	40	40				19.84	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	018	2	1	04	01	H4875_018_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	018	2	1	04	01	H4875_018_2	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.52	25	25	25				58.57	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											25.24	40	40	40				19.84	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	018	3	1	04	01	H4875_018_3	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	018	3	1	04	01	H4875_018_3	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.52	25	25	25				58.57	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											25.24	40	40	40				19.84	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	018	4	1	04	01	H4875_018_4	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	018	4	1	04	01	H4875_018_4	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.52	25	25	25				58.57	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											25.24	40	40	40				19.84	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	018	5	1	04	01	H4875_018_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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								12.00	24.00	36.00					7.00	14.00	21.00											12.00	24.00	36.00				7.00	14.00	0.00				12.00				12.00			0.40	0.23		0.40	0.23	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4875	018	5	1	04	01	H4875_018_5	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.52	25	25	25				58.57	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											25.24	40	40	40				19.84	35	35	35										40	40	40				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	020	1	1	04	01	H4875_020_1	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.67	25	25	25				61.65	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.45	30	30	30				14.54	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	020	2	1	04	01	H4875_020_2	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.67	25	25	25				61.65	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.45	30	30	30				14.54	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	020	3	1	04	01	H4875_020_3	6			Preferred Generic	4	01	1	2	1	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	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	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					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	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											67.67	25	25	25				61.65	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
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											18.45	30	30	30				14.54	25	25	25										30	30	30				25	25	25			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	022	1	1	04	01	H4875_022_1	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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					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	11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											12.85	25	25	25				9.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	022	2	1	04	01	H4875_022_2	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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					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	11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											12.85	25	25	25				9.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	022	5	1	04	01	H4875_022_5	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	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					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	11	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											12.85	25	25	25				9.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	27						1.00	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	024	1	1	04	01	H4875_024_1	6			Preferred Generic	4	01	1	2	1	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	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	024	1	1	04	01	H4875_024_1	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					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	024	1	1	04	01	H4875_024_1	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.04	21	21	21				61.49	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
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											14.93	25	25	25				15.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H4875	024	2	1	04	01	H4875_024_2	6			Preferred Generic	4	01	1	2	1	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	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	024	2	1	04	01	H4875_024_2	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					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	024	2	1	04	01	H4875_024_2	6			Preferred Brand	4	11	3	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											59.04	21	21	21				61.49	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
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											14.93	25	25	25				15.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	30						1.00	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	0.00		0.00																									0.00		0.00				0.00		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	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	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	25		25				25		25	25		25	25		25
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				54.78	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
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				98.10	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	25		25				25		25	25		25	25		25
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				632.40	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	009	1	1	04	01	H4882_009_1	11			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		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	11			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	25		25				25		25	25		25	25		25
H4882	009	1	1	04	01	H4882_009_1	11			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				62.88	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
H4882	009	1	1	04	01	H4882_009_1	11			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				90.43	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	25		25				25		25	25		25	25		25
H4882	009	1	1	04	01	H4882_009_1	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				579.55	25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	009	2	1	04	01	H4882_009_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	009	2	1	04	01	H4882_009_2	10			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	25		25				25		25	25		25	25		25
H4882	009	2	1	04	01	H4882_009_2	10			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				62.88	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
H4882	009	2	1	04	01	H4882_009_2	10			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				90.43	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	25		25				25		25	25		25	25		25
H4882	009	2	1	04	01	H4882_009_2	10			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				579.55	25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	011	1	1	04	01	H4882_011_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	011	1	1	04	01	H4882_011_1	9			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	25		25				25		25	25		25	25		25
H4882	011	1	1	04	01	H4882_011_1	9			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				64.34	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
H4882	011	1	1	04	01	H4882_011_1	9			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				96.01	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	25		25				25		25	25		25	25		25
H4882	011	1	1	04	01	H4882_011_1	9			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				570.14	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	011	2	1	04	01	H4882_011_2	8			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	011	2	1	04	01	H4882_011_2	8			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	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	25		25				25		25	25		25	25		25
H4882	011	2	1	04	01	H4882_011_2	8			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				64.34	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
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				96.01	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	25		25				25		25	25		25	25		25
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				570.14	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	014	1	1	04	01	H4882_014_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	014	1	1	04	01	H4882_014_1	7			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									5.00		15.00				5.00		10.00				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				5.00		15.00	5.00		10.00	5.00		5.00	25		25				25		25	25		25	25		25
H4882	014	1	1	04	01	H4882_014_1	7			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				63.86	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
H4882	014	1	1	04	01	H4882_014_1	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				92.32	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	25		25				25		25	25		25	25		25
H4882	014	1	1	04	01	H4882_014_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				598.36	25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4882	014	2	1	04	01	H4882_014_2	6			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		90				1	2				30		90	30		31	0.00		0.00																									0.00		0.00				0.00		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	014	2	1	04	01	H4882_014_2	6			Generic	4	11	1	2	2	1	110		01		110	1	30		90				1	2				30		90	30		31	5.00		15.00																									5.00		15.00				5.00		10.00				5.00				5.00		0.17				0.17	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				5.00		15.00	5.00		10.00	5.00		5.00	25		25				25		25	25		25	25		25
H4882	014	2	1	04	01	H4882_014_2	6			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		90				1	2				30		90	30		31				63.86	20		20																								20		20				20		20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	20		20				20		20	20		20	20		20
H4882	014	2	1	04	01	H4882_014_2	6			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		90				1	2				30		90	30		31				92.32	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	25		25				25		25	25		25	25		25
H4882	014	2	1	04	01	H4882_014_2	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				598.36	25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H4909	014	0	1	04	01	H4909_014_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								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	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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4909	014	0	1	04	01	H4909_014_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.00	25	25	25				82.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4909	014	0	1	04	01	H4909_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											26.00	30	30	30				20.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4909	014	0	1	04	01	H4909_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4909	014	0	1	04	01	H4909_014_0	6			Select Care Drugs	4	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	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																														
H4909	026	0	1	04	01	H4909_026_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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4909	026	0	1	04	01	H4909_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											53.00	25	25	25				83.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H4909	026	0	1	04	01	H4909_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											33.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H4909	026	0	1	04	01	H4909_026_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H4909	026	0	1	04	01	H4909_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																														
H4939	001	0	1	02	01	H4939_001_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	0		0				25		25	0		0	0		0
H4939	001	0	1	02	01	H4939_001_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	0		0				25		25	0		0	0		0
H4939	001	0	1	02	01	H4939_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4939	001	0	1	02	01	H4939_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4939	001	0	1	02	01	H4939_001_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	25						25			25			25		25
H4939	002	0	1	02	01	H4939_002_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	0		0				25		25	0		0	0		0
H4939	002	0	1	02	01	H4939_002_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	0		0				25		25	0		0	0		0
H4939	002	0	1	02	01	H4939_002_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4939	002	0	1	02	01	H4939_002_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4939	002	0	1	02	01	H4939_002_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	25						25			25			25		25
H4939	003	0	1	02	01	H4939_003_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	0		0				25		25	0		0	0		0
H4939	003	0	1	02	01	H4939_003_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	0		0				25		25	0		0	0		0
H4939	003	0	1	02	01	H4939_003_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H4939	003	0	1	02	01	H4939_003_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H4939	003	0	1	02	01	H4939_003_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	25						25			25			25		25
H4961	001	0	1	04	01	H4961_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H4961	001	0	1	04	01	H4961_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H4961	001	0	1	04	01	H4961_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	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	25	25	25				25	25	25				25		25
H4961	001	0	1	04	01	H4961_001_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.76	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		35.00	25	25	25				25	25	25				25		25
H4961	001	0	1	04	01	H4961_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				685.69	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	7			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	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	25	25	25				25	25	25				25		25
H4961	003	0	1	04	01	H4961_003_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H4961	003	0	1	04	01	H4961_003_0	7			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	25	25	25				25	25	25				25		25
H4961	003	0	1	04	01	H4961_003_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.13	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		35.00	25	25	25				25	25	25				25		25
H4961	003	0	1	04	01	H4961_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				713.89	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	7			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	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	25	25	25				25	25	25				25		25
H4961	006	0	1	04	01	H4961_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	25	25	25				25	25	25				25		25
H4961	006	0	1	04	01	H4961_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	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	25	25	25				25	25	25				25		25
H4961	006	0	1	04	01	H4961_006_0	8			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.19	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		35.00	25	25	25				25	25	25				25		25
H4961	006	0	1	04	01	H4961_006_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				436.57	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	8			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	01	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	01	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	01	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											80.57	24	24	24				103.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4982	001	0	1	01	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											46.21	25	25	25				52.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4982	001	0	1	01	01	H4982_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											489.22	25						609.87	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	25			25			25			25			25		25
H4982	002	0	1	01	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	01	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	01	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											74.41	24	24	24				99.98	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4982	002	0	1	01	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											46.90	25	25	25				48.94	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4982	002	0	1	01	01	H4982_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											501.34	25						588.99	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	25			25			25			25			25		25
H4982	003	0	1	01	01	H4982_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																														
H4982	003	0	1	01	01	H4982_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																														
H4982	003	0	1	01	01	H4982_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											79.87	24	24	24				100.66	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4982	003	0	1	01	01	H4982_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											39.29	25	25	25				44.31	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4982	003	0	1	01	01	H4982_003_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											537.41	25						621.06	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	25			25			25			25			25		25
H4982	004	0	1	01	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	01	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	01	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											81.53	24	24	24				104.01	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4982	004	0	1	01	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											39.86	25	25	25				47.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4982	004	0	1	01	01	H4982_004_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.98	25						678.96	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	25			25			25			25			25		25
H4982	007	0	1	01	01	H4982_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																														
H4982	007	0	1	01	01	H4982_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																														
H4982	007	0	1	01	01	H4982_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											69.91	24	24	24				97.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H4982	007	0	1	01	01	H4982_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											40.35	25	25	25				48.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H4982	007	0	1	01	01	H4982_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											548.94	25						673.79	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	25			25			25			25			25		25
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											71.43	22	22	22				89.35	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											40.11	25	25	25				49.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											505.35	25						624.60	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											67.89	24	24	24				98.42	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.31	25	25	25				50.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											609.93	25						735.54	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											65.90	24	24	24				94.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.28	25	25	25				49.31	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											571.46	25						676.21	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	25			25			25			25			25		25
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											61.97	24	24	24				93.11	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.95	25	25	25				47.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											552.74	25						660.06	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	25			25			25			25			25		25
H5008	002	0	1	02	01	H5008_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	002	0	1	02	01	H5008_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5008	002	0	1	02	01	H5008_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H5008	002	0	1	02	01	H5008_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	002	0	1	02	01	H5008_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				373.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	010	0	1	02	01	H5008_010_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	010	0	1	02	01	H5008_010_0	4		N	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																														
H5008	010	0	1	02	01	H5008_010_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	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	25		25						25				25		25
H5008	010	0	1	02	01	H5008_010_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5008	010	0	1	02	01	H5008_010_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				378.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	011	0	1	02	01	H5008_011_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	011	0	1	02	01	H5008_011_0	4		N	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																														
H5008	011	0	1	02	01	H5008_011_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H5008	011	0	1	02	01	H5008_011_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				43.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	011	0	1	02	01	H5008_011_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				381.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	015	0	1	02	01	H5008_015_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	015	0	1	02	01	H5008_015_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5008	015	0	1	02	01	H5008_015_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H5008	015	0	1	02	01	H5008_015_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	015	0	1	02	01	H5008_015_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				379.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	016	0	1	02	01	H5008_016_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	016	0	1	02	01	H5008_016_0	4		N	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																														
H5008	016	0	1	02	01	H5008_016_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	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	25		25						25				25		25
H5008	016	0	1	02	01	H5008_016_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	016	0	1	02	01	H5008_016_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				377.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	017	0	1	02	01	H5008_017_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	017	0	1	02	01	H5008_017_0	4		N	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																														
H5008	017	0	1	02	01	H5008_017_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H5008	017	0	1	02	01	H5008_017_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				41.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	017	0	1	02	01	H5008_017_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	018	0	1	02	01	H5008_018_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	018	0	1	02	01	H5008_018_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5008	018	0	1	02	01	H5008_018_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H5008	018	0	1	02	01	H5008_018_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				39.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	018	0	1	02	01	H5008_018_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				381.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	019	0	1	02	01	H5008_019_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	019	0	1	02	01	H5008_019_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5008	019	0	1	02	01	H5008_019_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H5008	019	0	1	02	01	H5008_019_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	019	0	1	02	01	H5008_019_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				397.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	020	0	1	02	01	H5008_020_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5008	020	0	1	02	01	H5008_020_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				6.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5008	020	0	1	02	01	H5008_020_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H5008	020	0	1	02	01	H5008_020_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5008	020	0	1	02	01	H5008_020_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				407.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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								8.00	16.00	16.00					4.00	8.00	8.00											8.00	16.00	16.00				4.00	8.00	0.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	16.00	4.00	8.00	8.00	8.00	16.00	16.00	4.00	8.00	0.00	8.00		8.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											29.34	23	23	23				29.34	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	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00	70.00	100.00	35.00		35.00	23	23	23	20	20	20	23	23	23	20	20	20	23		23
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											65.56	38	38	38				65.56	35	35	35										38	38	38				35	35	35			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											892.43	30						892.43	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5009	011	1	1	04	01	H5009_011_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	1	1	04	01	H5009_011_1	6			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					4.00	8.00	12.00											8.00	16.00	24.00				4.00	8.00	0.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	24.00	4.00	8.00	12.00	8.00	16.00	24.00	4.00	8.00	0.00	8.00		8.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	1	1	04	01	H5009_011_1	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.81	23	23	23				24.81	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	23	23	23	19	19	19	23	23	23	19	19	19	23		23
H5009	011	1	1	04	01	H5009_011_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											47.82	39	39	39				47.82	36	36	36										39	39	39				36	36	36			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	1	1	04	01	H5009_011_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											576.15	25						576.15	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5009	011	2	1	04	01	H5009_011_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	2	1	04	01	H5009_011_2	6			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					4.00	8.00	12.00											8.00	16.00	24.00				4.00	8.00	0.00				8.00				8.00			0.27	0.13		0.27	0.13	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00	16.00	24.00	4.00	8.00	12.00	8.00	16.00	24.00	4.00	8.00	0.00	8.00		8.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	2	1	04	01	H5009_011_2	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											24.81	23	23	23				24.81	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	23	23	23	19	19	19	23	23	23	19	19	19	23		23
H5009	011	2	1	04	01	H5009_011_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											47.82	39	39	39				47.82	36	36	36										39	39	39				36	36	36			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5009	011	2	1	04	01	H5009_011_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											576.15	25						576.15	25												25						25					25			25								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	25	25	25	0	0	0	0	0	0				25		25
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			0.67	0.17	0.17			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	5.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	004	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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												32	32	32					32	32	32				32	32	32															32			32								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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	0	0	0	0	0	0				25		25
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			0.67	0.17	0.17			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	5.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	009	0	1	01	01	H5050_009_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	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								5.00	10.00	15.00					2.00	4.00	6.00					0.00	0.00	0.00																5.00				5.00			0.17	0.07	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	2.00	4.00	6.00	0.00	0.00	0.00				5.00		5.00	25	25	25	25	25	25	0	0	0				25		25
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								15.00	30.00	45.00					10.00	20.00	30.00					10.00	0.00	0.00																15.00				15.00			0.50	0.33	0.33			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	10.00	20.00	30.00	10.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	25	0	0				25		25
H5050	017	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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												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	25	25	25	25	25	25	25	25	25				25		25
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					0.00	0.00	0.00																10.00				10.00			0.33	0.07	0.00			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	0.00	0.00	0.00				10.00		10.00	25	25	25	25	25	25	0	0	0				25		25
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			0.67	0.23	0.23			0.65	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	25	25	25	25	25	25	25	0	0				25		25
H5050	019	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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								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	25	25	25	25	25	25	25	25	25				25		25
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												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	25	25	25	25	25	25	25	25	25				25		25
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					0.00	0.00	0.00																10.00				10.00			0.33	0.07	0.00			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	0.00	0.00	0.00				10.00		10.00	25	25	25	25	25	25	0	0	0				25		25
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			0.67	0.23	0.23			0.65	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	25	25	25	25	25	25	25	0	0				25		25
H5050	021	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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								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	25	25	25	25	25	25	25	25	25				25		25
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												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	25	25	25	25	25	25	25	25	25				25		25
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	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	25	25	25	0	0	0	0	0	0				25		25
H5050	022	0	1	01	01	H5050_022_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			0.67	0.23	0.23			0.65	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	25	25	25	25	25	25	25	0	0				25		25
H5050	022	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	022	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	022	0	1	01	01	H5050_022_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	022	0	1	01	01	H5050_022_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	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								5.00	10.00	15.00					2.00	4.00	6.00					0.00	0.00	0.00																5.00				5.00			0.17	0.07	0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	2.00	4.00	6.00	0.00	0.00	0.00				5.00		5.00	25	25	25	25	25	25	0	0	0				25		25
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								15.00	30.00	45.00					10.00	20.00	30.00					10.00	0.00	0.00																15.00				15.00			0.50	0.33	0.33			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	10.00	20.00	30.00	10.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	25	0	0				25		25
H5050	023	0	1	01	01	H5050_023_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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																														
H5050	024	0	1	01	01	H5050_024_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					2.00	4.00	6.00					0.00	0.00	0.00																15.00				15.00			0.50	0.07	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	2.00	4.00	6.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	024	0	1	01	01	H5050_024_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	024	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	024	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	024	0	1	01	01	H5050_024_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	25	25	25	25	25	25	25	25	25				25		25
H5050	024	0	1	01	01	H5050_024_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	025	0	1	01	01	H5050_025_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					2.00	4.00	6.00					0.00	0.00	0.00																15.00				15.00			0.50	0.07	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	2.00	4.00	6.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	025	0	1	01	01	H5050_025_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	025	0	1	01	01	H5050_025_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	025	0	1	01	01	H5050_025_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	25	25	25	25	25	25	25	25	25				25		25
H5050	025	0	1	01	01	H5050_025_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	025	0	1	01	01	H5050_025_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	026	0	1	01	01	H5050_026_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					2.00	4.00	6.00					0.00	0.00	0.00																15.00				15.00			0.50	0.07	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	2.00	4.00	6.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	026	0	1	01	01	H5050_026_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	026	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	026	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	026	0	1	01	01	H5050_026_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	026	0	1	01	01	H5050_026_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	027	0	1	01	01	H5050_027_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					2.00	4.00	6.00					0.00	0.00	0.00																15.00				15.00			0.50	0.07	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	2.00	4.00	6.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	027	0	1	01	01	H5050_027_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	027	0	1	01	01	H5050_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	027	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	027	0	1	01	01	H5050_027_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	027	0	1	01	01	H5050_027_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	028	0	1	01	01	H5050_028_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					3.00	6.00	9.00					0.00	0.00	0.00																15.00				15.00			0.50	0.10	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	3.00	6.00	9.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	028	0	1	01	01	H5050_028_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	028	0	1	01	01	H5050_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	028	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	028	0	1	01	01	H5050_028_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	25	25	25	25	25	25	25	25	25				25		25
H5050	028	0	1	01	01	H5050_028_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	029	0	1	01	01	H5050_029_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					3.00	6.00	9.00					0.00	0.00	0.00																15.00				15.00			0.50	0.10	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	3.00	6.00	9.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	029	0	1	01	01	H5050_029_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	029	0	1	01	01	H5050_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	029	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	029	0	1	01	01	H5050_029_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	029	0	1	01	01	H5050_029_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	030	0	1	01	01	H5050_030_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					3.00	6.00	9.00					0.00	0.00	0.00																15.00				15.00			0.50	0.10	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	3.00	6.00	9.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	030	0	1	01	01	H5050_030_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	030	0	1	01	01	H5050_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	117.50																47.00				47.00			1.57	1.57	1.57			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	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	030	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	030	0	1	01	01	H5050_030_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	030	0	1	01	01	H5050_030_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	031	0	1	01	01	H5050_031_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					3.00	6.00	9.00					0.00	0.00	0.00																15.00				15.00			0.50	0.10	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	3.00	6.00	9.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	031	0	1	01	01	H5050_031_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	031	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	031	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	031	0	1	01	01	H5050_031_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5050	031	0	1	01	01	H5050_031_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	032	0	1	01	01	H5050_032_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					3.00	6.00	9.00					0.00	0.00	0.00																15.00				15.00			0.50	0.10	0.00			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	15.00	30.00	45.00	3.00	6.00	9.00	0.00	0.00	0.00				15.00		15.00	25	25	25	25	25	25	0	0	0				25		25
H5050	032	0	1	01	01	H5050_032_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					10.00	20.00	30.00					10.00	0.00	0.00																20.00				20.00			0.67	0.33	0.33			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	25	0	0				25		25
H5050	032	0	1	01	01	H5050_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					47.00	94.00	141.00					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, Vaccines	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5050	032	0	1	01	01	H5050_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								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	25	25	25	25	25	25	25	25	25				25		25
H5050	032	0	1	01	01	H5050_032_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	25	25	25	25	25	25	25	25	25				25		25
H5050	032	0	1	01	01	H5050_032_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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5087	005	0	1	01	01	H5087_005_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5087	005	0	1	01	01	H5087_005_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											110.70	25	25	25				110.70	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	005	0	1	01	01	H5087_005_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.92	31	31	31				97.92	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	005	0	1	01	01	H5087_005_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	005	0	1	01	01	H5087_005_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5087	032	0	1	01	01	H5087_032_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5087	032	0	1	01	01	H5087_032_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											116.24	25	25	25				116.24	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	032	0	1	01	01	H5087_032_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.54	42	42	42				97.54	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	032	0	1	01	01	H5087_032_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	032	0	1	01	01	H5087_032_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	034	1	1	01	01	H5087_034_1	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5087	034	1	1	01	01	H5087_034_1	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5087	034	1	1	01	01	H5087_034_1	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											115.99	25	25	25				115.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	034	1	1	01	01	H5087_034_1	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											87.10	37	37	37				84.75	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	034	1	1	01	01	H5087_034_1	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	034	1	1	01	01	H5087_034_1	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	034	2	1	01	01	H5087_034_2	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5087	034	2	1	01	01	H5087_034_2	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5087	034	2	1	01	01	H5087_034_2	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											115.99	25	25	25				115.99	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	034	2	1	01	01	H5087_034_2	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											87.10	37	37	37				84.75	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5087	034	2	1	01	01	H5087_034_2	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5087	034	2	1	01	01	H5087_034_2	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5106	029	1	1	04	01	H5106_029_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																														
H5106	029	1	1	04	01	H5106_029_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																														
H5106	029	1	1	04	01	H5106_029_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											73.80	20		20				73.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	029	1	1	04	01	H5106_029_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.38	25		25				68.38	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	20		20	20		20			20			20	20		20
H5106	029	1	1	04	01	H5106_029_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																														
H5106	029	2	1	04	01	H5106_029_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	029	2	1	04	01	H5106_029_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																														
H5106	029	2	1	04	01	H5106_029_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											73.80	20		20				73.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	029	2	1	04	01	H5106_029_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.38	25		25				68.38	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	20		20	20		20			20			20	20		20
H5106	029	2	1	04	01	H5106_029_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	029	3	1	04	01	H5106_029_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																														
H5106	029	3	1	04	01	H5106_029_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																														
H5106	029	3	1	04	01	H5106_029_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											73.80	20		20				73.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	029	3	1	04	01	H5106_029_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.38	25		25				68.38	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	20		20	20		20			20			20	20		20
H5106	029	3	1	04	01	H5106_029_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																														
H5106	030	1	1	04	01	H5106_030_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																														
H5106	030	1	1	04	01	H5106_030_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																														
H5106	030	1	1	04	01	H5106_030_1	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											72.77	19		19				72.77	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
H5106	030	1	1	04	01	H5106_030_1	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.42	20		20				48.42	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	030	1	1	04	01	H5106_030_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																														
H5106	030	2	1	04	01	H5106_030_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	030	2	1	04	01	H5106_030_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																														
H5106	030	2	1	04	01	H5106_030_2	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											72.77	19		19				72.77	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
H5106	030	2	1	04	01	H5106_030_2	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.42	20		20				48.42	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	030	2	1	04	01	H5106_030_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	030	3	1	04	01	H5106_030_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																														
H5106	030	3	1	04	01	H5106_030_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																														
H5106	030	3	1	04	01	H5106_030_3	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											72.77	19		19				72.77	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
H5106	030	3	1	04	01	H5106_030_3	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											48.42	20		20				48.42	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	030	3	1	04	01	H5106_030_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																														
H5106	034	1	1	04	01	H5106_034_1	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																														
H5106	034	1	1	04	01	H5106_034_1	5			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	034	1	1	04	01	H5106_034_1	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	20		20	20		20			20			20	20		20
H5106	034	1	1	04	01	H5106_034_1	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					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	20		20	20		20			20			20	20		20
H5106	034	1	1	04	01	H5106_034_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	034	2	1	04	01	H5106_034_2	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																														
H5106	034	2	1	04	01	H5106_034_2	5			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	034	2	1	04	01	H5106_034_2	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	20		20	20		20			20			20	20		20
H5106	034	2	1	04	01	H5106_034_2	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					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	20		20	20		20			20			20	20		20
H5106	034	2	1	04	01	H5106_034_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	035	0	1	04	01	H5106_035_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																														
H5106	035	0	1	04	01	H5106_035_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5106	035	0	1	04	01	H5106_035_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											81.59	22		22				81.59	22		22												22						22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	035	0	1	04	01	H5106_035_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											68.55	25		25				68.55	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	20		20	20		20			20			20	20		20
H5106	035	0	1	04	01	H5106_035_0	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	036	0	1	04	01	H5106_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																														
H5106	036	0	1	04	01	H5106_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																														
H5106	036	0	1	04	01	H5106_036_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											73.80	20		20				73.80	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	036	0	1	04	01	H5106_036_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.93	25		25				67.93	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	20		20	20		20			20			20	20		20
H5106	036	0	1	04	01	H5106_036_0	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	037	0	1	04	01	H5106_037_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																														
H5106	037	0	1	04	01	H5106_037_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5106	037	0	1	04	01	H5106_037_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											74.15	20		20				74.15	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	037	0	1	04	01	H5106_037_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											67.27	25		25				67.27	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5106	037	0	1	04	01	H5106_037_0	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																														
H5119	001	0	1	01	01	H5119_001_0	6		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, Select Care Drugs																														
H5119	001	0	1	01	01	H5119_001_0	6		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				14.82	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		35.00	25	25	25				25	25	25				25		25
H5119	001	0	1	01	01	H5119_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				151.10	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	25	25	25				25	25	25				25		25
H5119	001	0	1	01	01	H5119_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				200.90	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5119	001	0	1	01	01	H5119_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				897.99	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5119	001	0	1	01	01	H5119_001_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5141	004	0	1	04	01	H5141_004_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																														
H5141	004	0	1	04	01	H5141_004_0	5			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	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	25	25	25						25				25		25
H5141	004	0	1	04	01	H5141_004_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	25	25	25						25				25		25
H5141	004	0	1	04	01	H5141_004_0	5			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	25	25	25						25				25		25
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	25	25	25						25				25		25
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				82.14	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	25	25	25						25				25		25
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	25	25	25						25				25		25
H5141	025	0	1	04	01	H5141_025_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																														
H5141	025	0	1	04	01	H5141_025_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																					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	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	25	25	25						25				25		25
H5141	025	0	1	04	01	H5141_025_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	25	25	25						25				25		25
H5141	025	0	1	04	01	H5141_025_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	25	25	25						25				25		25
H5141	026	0	1	04	01	H5141_026_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																														
H5141	026	0	1	04	01	H5141_026_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																					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	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	25	25	25						25				25		25
H5141	026	0	1	04	01	H5141_026_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	25	25	25						25				25		25
H5141	026	0	1	04	01	H5141_026_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	25	25	25						25				25		25
H5141	032	0	1	04	01	H5141_032_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																														
H5141	032	0	1	04	01	H5141_032_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																					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	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	25	25	25						25				25		25
H5141	032	0	1	04	01	H5141_032_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	25	25	25						25				25		25
H5141	032	0	1	04	01	H5141_032_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	25	25	25						25				25		25
H5141	036	0	1	04	01	H5141_036_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																														
H5141	036	0	1	04	01	H5141_036_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																					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	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	25	25	25						25				25		25
H5141	036	0	1	04	01	H5141_036_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	25	25	25						25				25		25
H5141	036	0	1	04	01	H5141_036_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	25	25	25						25				25		25
H5141	038	0	1	04	01	H5141_038_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																														
H5141	038	0	1	04	01	H5141_038_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																					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	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	25	25	25						25				25		25
H5141	038	0	1	04	01	H5141_038_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	25	25	25						25				25		25
H5141	038	0	1	04	01	H5141_038_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	25	25	25						25				25		25
H5141	042	0	1	04	01	H5141_042_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	042	0	1	04	01	H5141_042_0	6			Generic	4	11	1	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 Drug, Specialty Tier																														
H5141	042	0	1	04	01	H5141_042_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				37.38	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	25	25	25						25				25		25
H5141	042	0	1	04	01	H5141_042_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				69.94	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	25	25	25						25				25		25
H5141	042	0	1	04	01	H5141_042_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	25	25	25						25				25		25
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	0.00	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			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				44.06	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	25	25	25						25				25		25
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				90.82	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	25	25	25						25				25		25
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					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	25	25	25						25				25		25
H5141	054	0	1	04	01	H5141_054_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																														
H5141	054	0	1	04	01	H5141_054_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																					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	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	25	25	25						25				25		25
H5141	054	0	1	04	01	H5141_054_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	25	25	25						25				25		25
H5141	054	0	1	04	01	H5141_054_0	5			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	25	25	25						25				25		25
H5141	063	0	1	04	01	H5141_063_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	063	0	1	04	01	H5141_063_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	063	0	1	04	01	H5141_063_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	25	25	25						25				25		25
H5141	063	0	1	04	01	H5141_063_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	25	25	25						25				25		25
H5141	063	0	1	04	01	H5141_063_0	6			Specialty Tier	4	11	1	1	5	1	111		01	100		1	30	60	100				1	2			100				30		31					26	26	26																				26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H5163	001	0	1	01	01	H5163_001_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	001	0	1	01	01	H5163_001_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	001	0	1	01	01	H5163_001_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	35.00	70.00	105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						70.00				35.00		35.00	25	25	25						25				25		25
H5163	001	0	1	01	01	H5163_001_0	8			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				39.10	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	25						25						25		25
H5163	001	0	1	01	01	H5163_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				245.01	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	25						25						25		25
H5163	001	0	1	01	01	H5163_001_0	8			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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	002	0	1	01	01	H5163_002_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	002	0	1	01	01	H5163_002_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	002	0	1	01	01	H5163_002_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			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 Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00						60.00				30.00		30.00	25	25	25						25				25		25
H5163	002	0	1	01	01	H5163_002_0	8			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				36.27	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	25						25						25		25
H5163	002	0	1	01	01	H5163_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				236.21	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	25						25						25		25
H5163	002	0	1	01	01	H5163_002_0	8			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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	003	0	1	01	01	H5163_003_0	8			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	003	0	1	01	01	H5163_003_0	8			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	003	0	1	01	01	H5163_003_0	8			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	40.00	80.00	120.00																					80.00																40.00				40.00		1.33						1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						80.00				35.00		35.00	25	25	25						25				25		25
H5163	003	0	1	01	01	H5163_003_0	8			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				39.64	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	25						25						25		25
H5163	003	0	1	01	01	H5163_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				250.13	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	25						25						25		25
H5163	003	0	1	01	01	H5163_003_0	8			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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	004	0	1	01	01	H5163_004_0	7			Preferred Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	004	0	1	01	01	H5163_004_0	7			Generic	4	11	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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5163	004	0	1	01	01	H5163_004_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	90				2	2			90				30		31	35.00	70.00	105.00																					70.00																35.00				35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						70.00				35.00		35.00	25	25	25						25				25		25
H5163	004	0	1	01	01	H5163_004_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				33.49	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	25						25						25		25
H5163	004	0	1	01	01	H5163_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				186.43	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	25						25						25		25
H5163	004	0	1	01	01	H5163_004_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 Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5178	002	0	1	01	01	H5178_002_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	0		0				25		25	0		0	0		0
H5178	002	0	1	01	01	H5178_002_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	0		0				25		25	0		0	0		0
H5178	002	0	1	01	01	H5178_002_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	25		25				25		25	25		25	25		25
H5178	002	0	1	01	01	H5178_002_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5178	002	0	1	01	01	H5178_002_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	25						25			25			25		25
H5209	005	1	1	01	01	H5209_005_1	9		N	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																														
H5209	005	1	1	01	01	H5209_005_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.62	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5209	005	1	1	01	01	H5209_005_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				26.48	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	20	20	20				20	20	20				20		20
H5209	005	1	1	01	01	H5209_005_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				57.66	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		35.00	25	25	25				25	25	25				25		25
H5209	005	1	1	01	01	H5209_005_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				379.38	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	25						25						25		25
H5209	005	1	1	01	01	H5209_005_1	9		N	Select Care Drugs	4	01	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																														
H5209	005	2	1	01	01	H5209_005_2	9		N	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																														
H5209	005	2	1	01	01	H5209_005_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.62	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5209	005	2	1	01	01	H5209_005_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				26.48	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	20	20	20				20	20	20				20		20
H5209	005	2	1	01	01	H5209_005_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				57.66	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		35.00	25	25	25				25	25	25				25		25
H5209	005	2	1	01	01	H5209_005_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				379.38	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	25						25						25		25
H5209	005	2	1	01	01	H5209_005_2	9		N	Select Care Drugs	4	01	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																														
H5209	006	1	1	01	01	H5209_006_1	9		N	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																														
H5209	006	1	1	01	01	H5209_006_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				3.78	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5209	006	1	1	01	01	H5209_006_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.36	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	20	20	20				20	20	20				20		20
H5209	006	1	1	01	01	H5209_006_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				58.46	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		35.00	25	25	25				25	25	25				25		25
H5209	006	1	1	01	01	H5209_006_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				433.61	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	25						25						25		25
H5209	006	1	1	01	01	H5209_006_1	9		N	Select Care Drugs	4	01	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																														
H5209	006	2	1	01	01	H5209_006_2	9		N	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																														
H5209	006	2	1	01	01	H5209_006_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				3.78	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5209	006	2	1	01	01	H5209_006_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.36	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	20	20	20				20	20	20				20		20
H5209	006	2	1	01	01	H5209_006_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				58.46	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		35.00	25	25	25				25	25	25				25		25
H5209	006	2	1	01	01	H5209_006_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				433.61	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	25						25						25		25
H5209	006	2	1	01	01	H5209_006_2	9		N	Select Care Drugs	4	01	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																														
H5211	002	0	1	02	01	H5211_002_0	10			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																														
H5211	002	0	1	02	01	H5211_002_0	10			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																														
H5211	002	0	1	02	01	H5211_002_0	10			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	25	25	25				25	25	25				25		25
H5211	002	0	1	02	01	H5211_002_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34				65.44	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		35.00	25	25	25				25	25	25				25		25
H5211	002	0	1	02	01	H5211_002_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				520.78	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	10			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	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																														
H5211	004	0	1	02	01	H5211_004_0	11			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																														
H5211	004	0	1	02	01	H5211_004_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	25	25	25				25	25	25				25		25
H5211	004	0	1	02	01	H5211_004_0	11			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34				64.59	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		35.00	25	25	25				25	25	25				25		25
H5211	004	0	1	02	01	H5211_004_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	34								34						34		34				605.47	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	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																														
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																														
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																														
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	25	25	25				25	25	25				25		25
H5211	012	0	1	02	01	H5211_012_0	11			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	34	68	102				1	2	34	68	102				34		34				68.67	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		35.00	25	25	25				25	25	25				25		25
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				506.34	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	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					0.00		0.00											8.00		20.00				0.00		0.00				0.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	002	0	1	04	01	H5215_002_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	002	0	1	04	01	H5215_002_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											57.45	25		25				49.76	23		23										25		25				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	25		25	23		23	25		25	23		23	23		23
H5215	002	0	1	04	01	H5215_002_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											108.97	25		25				76.69	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	25		25	25		25	25		25	25		25	25		25
H5215	002	0	1	04	01	H5215_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	005	0	1	04	01	H5215_005_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					0.00		0.00											8.00		20.00				0.00		0.00				0.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	005	0	1	04	01	H5215_005_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	005	0	1	04	01	H5215_005_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											56.14	25		25				47.11	23		23										25		25				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	25		25	23		23	25		25	23		23	23		23
H5215	005	0	1	04	01	H5215_005_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											118.24	25		25				73.78	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	25		25	25		25	25		25	25		25	25		25
H5215	005	0	1	04	01	H5215_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	008	0	1	04	01	H5215_008_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					1.00		2.00											8.00		20.00				1.00		0.00				1.00				1.00			0.27	0.03		0.27	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	008	0	1	04	01	H5215_008_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	008	0	1	04	01	H5215_008_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											53.81	25		25				49.67	21		21										25		25				21		21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	21		21	25		25	21		21	21		21
H5215	008	0	1	04	01	H5215_008_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											98.18	29		29				84.35	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5215	008	0	1	04	01	H5215_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												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	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					0.00		0.00											8.00		20.00				0.00		0.00				0.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	009	0	1	04	01	H5215_009_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	009	0	1	04	01	H5215_009_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											51.39	25		25				53.07	23		23										25		25				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	25		25	23		23	25		25	23		23	23		23
H5215	009	0	1	04	01	H5215_009_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											103.39	25		25				81.96	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	25		25	25		25	25		25	25		25	25		25
H5215	009	0	1	04	01	H5215_009_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												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	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					1.00		2.00											8.00		20.00				1.00		0.00				1.00				1.00			0.27	0.03		0.27	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	010	0	1	04	01	H5215_010_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	010	0	1	04	01	H5215_010_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											62.86	25		25				52.38	22		22										25		25				22		22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	22		22	25		25	22		22	22		22
H5215	010	0	1	04	01	H5215_010_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											97.29	28		28				89.87	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5215	010	0	1	04	01	H5215_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	011	0	1	04	01	H5215_011_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					1.00		2.00											8.00		20.00				1.00		0.00				1.00				1.00			0.27	0.03		0.27	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	011	0	1	04	01	H5215_011_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	011	0	1	04	01	H5215_011_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											56.09	25		25				54.04	23		23										25		25				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	25		25	23		23	25		25	23		23	23		23
H5215	011	0	1	04	01	H5215_011_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											99.40	28		28				83.79	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5215	011	0	1	04	01	H5215_011_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												29							29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	012	0	1	04	01	H5215_012_0	5			Preferred Generic	4	01	1	2	1	1		110	01		110	1				30		100	1	2				30		100	30		31								8.00		20.00					0.00		0.00											8.00		20.00				0.00		0.00				0.00				0.00			0.27	0.00		0.27	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	012	0	1	04	01	H5215_012_0	5			Generic	4	01	1	2	2	1		110	01		110	1				30		90	1	2				30		90	30		31								17.00		42.00					8.00		20.00											17.00		42.00				8.00		0.00				8.00				8.00			0.57	0.27		0.57	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5215	012	0	1	04	01	H5215_012_0	5			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	1	2				30		90	30		31											42.21	25		25				50.06	23		23										25		25				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	25		25	23		23	25		25	23		23	23		23
H5215	012	0	1	04	01	H5215_012_0	5			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				30		90	1	2				30		90	30		31											163.38	25		25				89.38	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	25		25	25		25	25		25	25		25	25		25
H5215	012	0	1	04	01	H5215_012_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																														
H5216	001	0	1	04	01	H5216_001_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	0		0				25		25	0		0	0		0
H5216	001	0	1	04	01	H5216_001_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	001	0	1	04	01	H5216_001_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	25		25				25		25	25		25	25		25
H5216	001	0	1	04	01	H5216_001_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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	25		25				25		25	25		25	25		25
H5216	001	0	1	04	01	H5216_001_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	25						25			25			25		25
H5216	006	0	1	04	01	H5216_006_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	0		0				25		25	0		0	0		0
H5216	006	0	1	04	01	H5216_006_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	006	0	1	04	01	H5216_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	25		25				25		25	25		25	25		25
H5216	006	0	1	04	01	H5216_006_0	3			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	25		25				25		25	25		25	25		25
H5216	006	0	1	04	01	H5216_006_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	25						25			25			25		25
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	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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	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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	013	0	1	04	01	H5216_013_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	0		0				25		25	0		0	0		0
H5216	013	0	1	04	01	H5216_013_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	013	0	1	04	01	H5216_013_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	25		25				25		25	25		25	25		25
H5216	013	0	1	04	01	H5216_013_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H5216	013	0	1	04	01	H5216_013_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	25						25			25			25		25
H5216	014	0	1	04	01	H5216_014_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	0		0				25		25	0		0	0		0
H5216	014	0	1	04	01	H5216_014_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	014	0	1	04	01	H5216_014_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	25		25				25		25	25		25	25		25
H5216	014	0	1	04	01	H5216_014_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	014	0	1	04	01	H5216_014_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	25						25			25			25		25
H5216	017	0	1	04	01	H5216_017_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	0		0				25		25	0		0	0		0
H5216	017	0	1	04	01	H5216_017_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	017	0	1	04	01	H5216_017_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	25		25				25		25	25		25	25		25
H5216	017	0	1	04	01	H5216_017_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5216	017	0	1	04	01	H5216_017_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	25						25			25			25		25
H5216	019	0	1	04	01	H5216_019_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	0		0				25		25	0		0	0		0
H5216	019	0	1	04	01	H5216_019_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	25		25				25		25	25		0	25		25
H5216	019	0	1	04	01	H5216_019_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	25		25				25		25	25		25	25		25
H5216	019	0	1	04	01	H5216_019_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	25		25				25		25	25		25	25		25
H5216	019	0	1	04	01	H5216_019_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	25						25			25			25		25
H5216	023	0	1	04	01	H5216_023_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	0		0				25		25	0		0	0		0
H5216	023	0	1	04	01	H5216_023_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	25		25				25		25	25		0	25		25
H5216	023	0	1	04	01	H5216_023_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	25		25				25		25	25		25	25		25
H5216	023	0	1	04	01	H5216_023_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	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	25		25				25		25	25		25	25		25
H5216	023	0	1	04	01	H5216_023_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	25						25			25			25		25
H5216	027	0	1	04	01	H5216_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	0		0				25		25	0		0	0		0
H5216	027	0	1	04	01	H5216_027_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	027	0	1	04	01	H5216_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	25		25				25		25	25		25	25		25
H5216	027	0	1	04	01	H5216_027_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	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	25		25				25		25	25		25	25		25
H5216	027	0	1	04	01	H5216_027_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	25						25			25			25		25
H5216	032	0	1	04	01	H5216_032_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	0		0				25		25	0		0	0		0
H5216	032	0	1	04	01	H5216_032_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	032	0	1	04	01	H5216_032_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	25		25				25		25	25		25	25		25
H5216	032	0	1	04	01	H5216_032_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
H5216	032	0	1	04	01	H5216_032_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	25						25			25			25		25
H5216	034	0	1	04	01	H5216_034_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	0		0				25		25	0		0	0		0
H5216	034	0	1	04	01	H5216_034_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	034	0	1	04	01	H5216_034_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	25		25				25		25	25		25	25		25
H5216	034	0	1	04	01	H5216_034_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	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	25		25				25		25	25		25	25		25
H5216	034	0	1	04	01	H5216_034_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	25						25			25			25		25
H5216	037	0	1	04	01	H5216_037_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	0		0				25		25	0		0	0		0
H5216	037	0	1	04	01	H5216_037_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	0		0				25		25	0		0	0		0
H5216	037	0	1	04	01	H5216_037_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	25		25				25		25	25		25	25		25
H5216	037	0	1	04	01	H5216_037_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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	25		25				25		25	25		25	25		25
H5216	037	0	1	04	01	H5216_037_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	25						25			25			25		25
H5216	039	0	1	04	01	H5216_039_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	0		0				25		25	0		0	0		0
H5216	039	0	1	04	01	H5216_039_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	0		0				25		25	0		0	0		0
H5216	039	0	1	04	01	H5216_039_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	25		25				25		25	25		25	25		25
H5216	039	0	1	04	01	H5216_039_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	039	0	1	04	01	H5216_039_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	25						25			25			25		25
H5216	042	0	1	04	01	H5216_042_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	0		0				25		25	0		0	0		0
H5216	042	0	1	04	01	H5216_042_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	25		25				25		25	25		0	25		25
H5216	042	0	1	04	01	H5216_042_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	25		25				25		25	25		25	25		25
H5216	042	0	1	04	01	H5216_042_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	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	25		25				25		25	25		25	25		25
H5216	042	0	1	04	01	H5216_042_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	25						25			25			25		25
H5216	043	1	1	04	01	H5216_043_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	0		0				25		25	0		0	0		0
H5216	043	1	1	04	01	H5216_043_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	043	1	1	04	01	H5216_043_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	25		25				25		25	25		25	25		25
H5216	043	1	1	04	01	H5216_043_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H5216	043	1	1	04	01	H5216_043_1	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	25						25			25			25		25
H5216	043	5	1	04	01	H5216_043_5	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	0		0				25		25	0		0	0		0
H5216	043	5	1	04	01	H5216_043_5	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	043	5	1	04	01	H5216_043_5	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	25		25				25		25	25		25	25		25
H5216	043	5	1	04	01	H5216_043_5	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H5216	043	5	1	04	01	H5216_043_5	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	25						25			25			25		25
H5216	043	6	1	04	01	H5216_043_6	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	0		0				25		25	0		0	0		0
H5216	043	6	1	04	01	H5216_043_6	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	043	6	1	04	01	H5216_043_6	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	25		25				25		25	25		25	25		25
H5216	043	6	1	04	01	H5216_043_6	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				84.00	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	25		25				25		25	25		25	25		25
H5216	043	6	1	04	01	H5216_043_6	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	25						25			25			25		25
H5216	048	0	1	04	01	H5216_048_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	0		0				25		25	0		0	0		0
H5216	048	0	1	04	01	H5216_048_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	25		25				25		25	25		0	25		25
H5216	048	0	1	04	01	H5216_048_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	25		25				25		25	25		25	25		25
H5216	048	0	1	04	01	H5216_048_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	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	25		25				25		25	25		25	25		25
H5216	048	0	1	04	01	H5216_048_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	25						25			25			25		25
H5216	053	0	1	04	01	H5216_053_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	0		0				25		25	0		0	0		0
H5216	053	0	1	04	01	H5216_053_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	053	0	1	04	01	H5216_053_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	25		25				25		25	25		25	25		25
H5216	053	0	1	04	01	H5216_053_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	053	0	1	04	01	H5216_053_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	25						25			25			25		25
H5216	062	0	1	04	01	H5216_062_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	0		0				25		25	0		0	0		0
H5216	062	0	1	04	01	H5216_062_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	062	0	1	04	01	H5216_062_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	25		25				25		25	25		25	25		25
H5216	062	0	1	04	01	H5216_062_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	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	25		25				25		25	25		25	25		25
H5216	062	0	1	04	01	H5216_062_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	25						25			25			25		25
H5216	063	0	1	04	01	H5216_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	0		0				25		25	0		0	0		0
H5216	063	0	1	04	01	H5216_063_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	063	0	1	04	01	H5216_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	25		25				25		25	25		25	25		25
H5216	063	0	1	04	01	H5216_063_0	3			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	25		25				25		25	25		25	25		25
H5216	063	0	1	04	01	H5216_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	25						25			25			25		25
H5216	064	0	1	04	01	H5216_064_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	0		0				25		25	0		0	0		0
H5216	064	0	1	04	01	H5216_064_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	25		25				25		25	25		0	25		25
H5216	064	0	1	04	01	H5216_064_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	25		25				25		25	25		25	25		25
H5216	064	0	1	04	01	H5216_064_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	064	0	1	04	01	H5216_064_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	068	0	1	04	01	H5216_068_0	2			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	0		0				25		25	0		0	0		0
H5216	068	0	1	04	01	H5216_068_0	2			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	0		0				25		25	0		0	0		0
H5216	068	0	1	04	01	H5216_068_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	068	0	1	04	01	H5216_068_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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	25		25				25		25	25		25	25		25
H5216	068	0	1	04	01	H5216_068_0	2			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	25						25			25			25		25
H5216	070	0	1	04	01	H5216_070_0	2			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	0		0				25		25	0		0	0		0
H5216	070	0	1	04	01	H5216_070_0	2			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	25		25				25		25	25		0	25		25
H5216	070	0	1	04	01	H5216_070_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	070	0	1	04	01	H5216_070_0	2			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	25		25				25		25	25		25	25		25
H5216	070	0	1	04	01	H5216_070_0	2			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	25						25			25			25		25
H5216	072	0	1	04	01	H5216_072_0	2			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	0		0				25		25	0		0	0		0
H5216	072	0	1	04	01	H5216_072_0	2			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	25		25				25		25	25		0	25		25
H5216	072	0	1	04	01	H5216_072_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	072	0	1	04	01	H5216_072_0	2			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	25		25				25		25	25		25	25		25
H5216	072	0	1	04	01	H5216_072_0	2			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	25						25			25			25		25
H5216	073	0	1	04	01	H5216_073_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	0		0				25		25	0		0	0		0
H5216	073	0	1	04	01	H5216_073_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	073	0	1	04	01	H5216_073_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	25		25				25		25	25		25	25		25
H5216	073	0	1	04	01	H5216_073_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	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	25		25				25		25	25		25	25		25
H5216	073	0	1	04	01	H5216_073_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	25						25			25			25		25
H5216	074	0	1	04	01	H5216_074_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	0		0				25		25	0		0	0		0
H5216	074	0	1	04	01	H5216_074_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	25		25				25		25	25		0	25		25
H5216	074	0	1	04	01	H5216_074_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	25		25				25		25	25		25	25		25
H5216	074	0	1	04	01	H5216_074_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	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	25		25				25		25	25		25	25		25
H5216	074	0	1	04	01	H5216_074_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	25						25			25			25		25
H5216	078	1	1	04	01	H5216_078_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	0		0				25		25	0		0	0		0
H5216	078	1	1	04	01	H5216_078_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	25		25				25		25	25		0	25		25
H5216	078	1	1	04	01	H5216_078_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		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	25		25				25		25	25		25	25		25
H5216	078	1	1	04	01	H5216_078_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	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	25		25				25		25	25		25	25		25
H5216	078	1	1	04	01	H5216_078_1	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	25						25			25			25		25
H5216	078	2	1	04	01	H5216_078_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	0		0				25		25	0		0	0		0
H5216	078	2	1	04	01	H5216_078_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	25		25				25		25	25		0	25		25
H5216	078	2	1	04	01	H5216_078_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		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	25		25				25		25	25		25	25		25
H5216	078	2	1	04	01	H5216_078_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	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	25		25				25		25	25		25	25		25
H5216	078	2	1	04	01	H5216_078_2	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	25						25			25			25		25
H5216	078	6	1	04	01	H5216_078_6	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	0		0				25		25	0		0	0		0
H5216	078	6	1	04	01	H5216_078_6	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	25		25				25		25	25		0	25		25
H5216	078	6	1	04	01	H5216_078_6	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	25		25				25		25	25		25	25		25
H5216	078	6	1	04	01	H5216_078_6	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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	25		25				25		25	25		25	25		25
H5216	078	6	1	04	01	H5216_078_6	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	25						25			25			25		25
H5216	081	0	1	04	01	H5216_081_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	0		0				25		25	0		0	0		0
H5216	081	0	1	04	01	H5216_081_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	25		25				25		25	25		0	25		25
H5216	081	0	1	04	01	H5216_081_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	25		25				25		25	25		25	25		25
H5216	081	0	1	04	01	H5216_081_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	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	083	0	1	04	01	H5216_083_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	0		0				25		25	0		0	0		0
H5216	083	0	1	04	01	H5216_083_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	25		25				25		25	25		0	25		25
H5216	083	0	1	04	01	H5216_083_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	25		25				25		25	25		25	25		25
H5216	083	0	1	04	01	H5216_083_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	25		25				25		25	25		25	25		25
H5216	083	0	1	04	01	H5216_083_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				70.00	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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	092	0	1	04	01	H5216_092_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	0		0				25		25	0		0	0		0
H5216	092	0	1	04	01	H5216_092_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	092	0	1	04	01	H5216_092_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	25		25				25		25	25		25	25		25
H5216	092	0	1	04	01	H5216_092_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5216	097	0	1	04	01	H5216_097_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	0		0				25		25	0		0	0		0
H5216	097	0	1	04	01	H5216_097_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	097	0	1	04	01	H5216_097_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	25		25				25		25	25		25	25		25
H5216	097	0	1	04	01	H5216_097_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	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	25		25				25		25	25		25	25		25
H5216	097	0	1	04	01	H5216_097_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	25						25			25			25		25
H5216	100	0	1	04	01	H5216_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	0		0				25		25	0		0	0		0
H5216	100	0	1	04	01	H5216_100_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	100	0	1	04	01	H5216_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	25		25				25		25	25		25	25		25
H5216	100	0	1	04	01	H5216_100_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	100	0	1	04	01	H5216_100_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	25						25			25			25		25
H5216	106	0	1	04	01	H5216_106_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	0		0				25		25	0		0	0		0
H5216	106	0	1	04	01	H5216_106_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	25		25				25		25	25		0	25		25
H5216	106	0	1	04	01	H5216_106_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	25		25				25		25	25		25	25		25
H5216	106	0	1	04	01	H5216_106_0	3			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	25		25				25		25	25		25	25		25
H5216	106	0	1	04	01	H5216_106_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	25						25			25			25		25
H5216	114	0	1	04	01	H5216_114_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	0		0				25		25	0		0	0		0
H5216	114	0	1	04	01	H5216_114_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	25		25				25		25	25		0	25		25
H5216	114	0	1	04	01	H5216_114_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	25		25				25		25	25		25	25		25
H5216	114	0	1	04	01	H5216_114_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	114	0	1	04	01	H5216_114_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	25						25			25			25		25
H5216	120	0	1	04	01	H5216_120_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	0		0				25		25	0		0	0		0
H5216	120	0	1	04	01	H5216_120_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	120	0	1	04	01	H5216_120_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	25		25				25		25	25		25	25		25
H5216	120	0	1	04	01	H5216_120_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	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	25		25				25		25	25		25	25		25
H5216	120	0	1	04	01	H5216_120_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	25						25			25			25		25
H5216	124	0	1	04	01	H5216_124_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	0		0				25		25	0		0	0		0
H5216	124	0	1	04	01	H5216_124_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	25		25				25		25	25		0	25		25
H5216	124	0	1	04	01	H5216_124_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	25		25				25		25	25		25	25		25
H5216	124	0	1	04	01	H5216_124_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	124	0	1	04	01	H5216_124_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	136	0	1	04	01	H5216_136_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	0		0				25		25	0		0	0		0
H5216	136	0	1	04	01	H5216_136_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	136	0	1	04	01	H5216_136_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	25		25				25		25	25		25	25		25
H5216	136	0	1	04	01	H5216_136_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	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	25		25				25		25	25		25	25		25
H5216	136	0	1	04	01	H5216_136_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	25						25			25			25		25
H5216	138	0	1	04	01	H5216_138_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	0		0				25		25	0		0	0		0
H5216	138	0	1	04	01	H5216_138_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	138	0	1	04	01	H5216_138_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	25		25				25		25	25		25	25		25
H5216	138	0	1	04	01	H5216_138_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5216	138	0	1	04	01	H5216_138_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	25						25			25			25		25
H5216	141	0	1	04	01	H5216_141_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	0		0				25		25	0		0	0		0
H5216	141	0	1	04	01	H5216_141_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	141	0	1	04	01	H5216_141_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	25		25				25		25	25		25	25		25
H5216	141	0	1	04	01	H5216_141_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	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	25		25				25		25	25		25	25		25
H5216	141	0	1	04	01	H5216_141_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	25						25			25			25		25
H5216	144	0	1	04	01	H5216_144_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	0		0				25		25	0		0	0		0
H5216	144	0	1	04	01	H5216_144_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	144	0	1	04	01	H5216_144_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	25		25				25		25	25		25	25		25
H5216	144	0	1	04	01	H5216_144_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	144	0	1	04	01	H5216_144_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	25						25			25			25		25
H5216	154	0	1	04	01	H5216_154_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	0		0				25		25	0		0	0		0
H5216	154	0	1	04	01	H5216_154_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	154	0	1	04	01	H5216_154_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	25		25				25		25	25		25	25		25
H5216	154	0	1	04	01	H5216_154_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	154	0	1	04	01	H5216_154_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	25						25			25			25		25
H5216	164	0	1	04	01	H5216_164_0	4		N	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	0		0				25		25	0		0	0		0
H5216	164	0	1	04	01	H5216_164_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	0		0				25		25	0		0	0		0
H5216	164	0	1	04	01	H5216_164_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	164	0	1	04	01	H5216_164_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	164	0	1	04	01	H5216_164_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	25						25			25			25		25
H5216	168	0	1	04	01	H5216_168_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	0		0				25		25	0		0	0		0
H5216	168	0	1	04	01	H5216_168_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	168	0	1	04	01	H5216_168_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	25		25				25		25	25		25	25		25
H5216	168	0	1	04	01	H5216_168_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	25		25				25		25	25		25	25		25
H5216	168	0	1	04	01	H5216_168_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	25						25			25			25		25
H5216	175	0	1	04	01	H5216_175_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	0		0				25		25	0		0	0		0
H5216	175	0	1	04	01	H5216_175_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	25		25				25		25	25		0	25		25
H5216	175	0	1	04	01	H5216_175_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	25		25				25		25	25		25	25		25
H5216	175	0	1	04	01	H5216_175_0	5			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	25		25				25		25	25		25	25		25
H5216	175	0	1	04	01	H5216_175_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	188	0	1	04	01	H5216_188_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	0		0				25		25	0		0	0		0
H5216	188	0	1	04	01	H5216_188_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	188	0	1	04	01	H5216_188_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	25		25				25		25	25		25	25		25
H5216	188	0	1	04	01	H5216_188_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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	192	0	1	04	01	H5216_192_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	0		0				25		25	0		0	0		0
H5216	192	0	1	04	01	H5216_192_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	192	0	1	04	01	H5216_192_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	25		25				25		25	25		25	25		25
H5216	192	0	1	04	01	H5216_192_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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	25		25				25		25	25		25	25		25
H5216	192	0	1	04	01	H5216_192_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	25						25			25			25		25
H5216	194	0	1	04	01	H5216_194_0	2			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	0		0				25		25	0		0	0		0
H5216	194	0	1	04	01	H5216_194_0	2			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	25		25				25		25	25		0	25		25
H5216	194	0	1	04	01	H5216_194_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	194	0	1	04	01	H5216_194_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H5216	194	0	1	04	01	H5216_194_0	2			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	25						25			25			25		25
H5216	196	1	1	04	01	H5216_196_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	0		0				25		25	0		0	0		0
H5216	196	1	1	04	01	H5216_196_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	25		25				25		25	25		0	25		25
H5216	196	1	1	04	01	H5216_196_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		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	25		25				25		25	25		25	25		25
H5216	196	1	1	04	01	H5216_196_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H5216	196	1	1	04	01	H5216_196_1	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	25						25			25			25		25
H5216	196	2	1	04	01	H5216_196_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	0		0				25		25	0		0	0		0
H5216	196	2	1	04	01	H5216_196_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	25		25				25		25	25		0	25		25
H5216	196	2	1	04	01	H5216_196_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		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	25		25				25		25	25		25	25		25
H5216	196	2	1	04	01	H5216_196_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H5216	196	2	1	04	01	H5216_196_2	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	25						25			25			25		25
H5216	203	1	1	04	01	H5216_203_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	0		0				25		25	0		0	0		0
H5216	203	1	1	04	01	H5216_203_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	203	1	1	04	01	H5216_203_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	25		25				25		25	25		25	25		25
H5216	203	1	1	04	01	H5216_203_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	203	1	1	04	01	H5216_203_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	25						25			25			25		25
H5216	203	2	1	04	01	H5216_203_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	0		0				25		25	0		0	0		0
H5216	203	2	1	04	01	H5216_203_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	203	2	1	04	01	H5216_203_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	25		25				25		25	25		25	25		25
H5216	203	2	1	04	01	H5216_203_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	203	2	1	04	01	H5216_203_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	25						25			25			25		25
H5216	205	0	1	04	01	H5216_205_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	0		0				25		25	0		0	0		0
H5216	205	0	1	04	01	H5216_205_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	0		0				25		25	0		0	0		0
H5216	205	0	1	04	01	H5216_205_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	205	0	1	04	01	H5216_205_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	205	0	1	04	01	H5216_205_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	25						25			25			25		25
H5216	207	0	1	04	01	H5216_207_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	0		0				25		25	0		0	0		0
H5216	207	0	1	04	01	H5216_207_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	207	0	1	04	01	H5216_207_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	25		25				25		25	25		25	25		25
H5216	207	0	1	04	01	H5216_207_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	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	25		25				25		25	25		25	25		25
H5216	207	0	1	04	01	H5216_207_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	25						25			25			25		25
H5216	211	0	1	04	01	H5216_211_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	0		0				25		25	0		0	0		0
H5216	211	0	1	04	01	H5216_211_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	211	0	1	04	01	H5216_211_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	25		25				25		25	25		25	25		25
H5216	211	0	1	04	01	H5216_211_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
H5216	211	0	1	04	01	H5216_211_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	25						25			25			25		25
H5216	219	0	1	04	01	H5216_219_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	0		0				25		25	0		0	0		0
H5216	219	0	1	04	01	H5216_219_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	0		0				25		25	0		0	0		0
H5216	219	0	1	04	01	H5216_219_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	219	0	1	04	01	H5216_219_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	219	0	1	04	01	H5216_219_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	25						25			25			25		25
H5216	220	0	1	04	01	H5216_220_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	0		0				25		25	0		0	0		0
H5216	220	0	1	04	01	H5216_220_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	0		0				25		25	0		0	0		0
H5216	220	0	1	04	01	H5216_220_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	220	0	1	04	01	H5216_220_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	220	0	1	04	01	H5216_220_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	25						25			25			25		25
H5216	223	0	1	04	01	H5216_223_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	0		0				25		25	0		0	0		0
H5216	223	0	1	04	01	H5216_223_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	25		25				25		25	25		0	25		25
H5216	223	0	1	04	01	H5216_223_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	25		25				25		25	25		25	25		25
H5216	223	0	1	04	01	H5216_223_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	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	25		25				25		25	25		25	25		25
H5216	223	0	1	04	01	H5216_223_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	25						25			25			25		25
H5216	224	0	1	04	01	H5216_224_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	0		0				25		25	0		0	0		0
H5216	224	0	1	04	01	H5216_224_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	0		0				25		25	0		0	0		0
H5216	224	0	1	04	01	H5216_224_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	25		25				25		25	25		25	25		25
H5216	224	0	1	04	01	H5216_224_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H5216	224	0	1	04	01	H5216_224_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	25						25			25			25		25
H5216	226	0	1	04	01	H5216_226_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	0		0				25		25	0		0	0		0
H5216	226	0	1	04	01	H5216_226_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	226	0	1	04	01	H5216_226_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	25		25				25		25	25		25	25		25
H5216	226	0	1	04	01	H5216_226_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	227	0	1	04	01	H5216_227_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	0		0				25		25	0		0	0		0
H5216	227	0	1	04	01	H5216_227_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	0		0				25		25	0		0	0		0
H5216	227	0	1	04	01	H5216_227_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	227	0	1	04	01	H5216_227_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	227	0	1	04	01	H5216_227_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	25						25			25			25		25
H5216	228	0	1	04	01	H5216_228_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	0		0				25		25	0		0	0		0
H5216	228	0	1	04	01	H5216_228_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	0		0				25		25	0		0	0		0
H5216	228	0	1	04	01	H5216_228_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	228	0	1	04	01	H5216_228_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	228	0	1	04	01	H5216_228_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	25						25			25			25		25
H5216	229	0	1	04	01	H5216_229_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	0		0				25		25	0		0	0		0
H5216	229	0	1	04	01	H5216_229_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	229	0	1	04	01	H5216_229_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	25		25				25		25	25		25	25		25
H5216	229	0	1	04	01	H5216_229_0	3			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	25		25				25		25	25		25	25		25
H5216	229	0	1	04	01	H5216_229_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	25						25			25			25		25
H5216	231	0	1	04	01	H5216_231_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	0		0				25		25	0		0	0		0
H5216	231	0	1	04	01	H5216_231_0	3			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	25		25				25		25	25		0	25		25
H5216	231	0	1	04	01	H5216_231_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	25		25				25		25	25		25	25		25
H5216	231	0	1	04	01	H5216_231_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
H5216	231	0	1	04	01	H5216_231_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	25						25			25			25		25
H5216	242	0	1	04	01	H5216_242_0	3			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				2.00	20		20																								25		25				20		0			20			20								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	20		20				25		25	20		0	20		20
H5216	242	0	1	04	01	H5216_242_0	3			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	25		25				25		25	25		0	25		25
H5216	242	0	1	04	01	H5216_242_0	3			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				24.00	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	25		25				25		25	25		25	25		25
H5216	242	0	1	04	01	H5216_242_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	242	0	1	04	01	H5216_242_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	25						25			25			25		25
H5216	244	0	1	04	01	H5216_244_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	0		0				25		25	0		0	0		0
H5216	244	0	1	04	01	H5216_244_0	7			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	244	0	1	04	01	H5216_244_0	7			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	244	0	1	04	01	H5216_244_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	25		25				25		25	25		25	25		25
H5216	244	0	1	04	01	H5216_244_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	244	0	1	04	01	H5216_244_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	0		0				0		0	0		0	0		0
H5216	246	0	1	04	01	H5216_246_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	0		0				25		25	0		0	0		0
H5216	246	0	1	04	01	H5216_246_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	25		25				25		25	25		0	25		25
H5216	246	0	1	04	01	H5216_246_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	246	0	1	04	01	H5216_246_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	49		49																								49		49				49		49			49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	246	0	1	04	01	H5216_246_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	246	0	1	04	01	H5216_246_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	0		0				0		0	0		0	0		0
H5216	249	0	1	04	01	H5216_249_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	0		0				25		25	0		0	0		0
H5216	249	0	1	04	01	H5216_249_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	249	0	1	04	01	H5216_249_0	3			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	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	249	0	1	04	01	H5216_249_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	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	25		25				25		25	25		25	25		25
H5216	249	0	1	04	01	H5216_249_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	25						25			25			25		25
H5216	251	0	1	04	01	H5216_251_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	0		0				25		25	0		0	0		0
H5216	251	0	1	04	01	H5216_251_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	25		25				25		25	25		0	25		25
H5216	251	0	1	04	01	H5216_251_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	25		25				25		25	25		25	25		25
H5216	251	0	1	04	01	H5216_251_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	25		25				25		25	25		25	25		25
H5216	251	0	1	04	01	H5216_251_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	25						25			25			25		25
H5216	252	0	1	04	01	H5216_252_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	0		0				25		25	0		0	0		0
H5216	252	0	1	04	01	H5216_252_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	25		25				25		25	25		0	25		25
H5216	252	0	1	04	01	H5216_252_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	25		25				25		25	25		25	25		25
H5216	252	0	1	04	01	H5216_252_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	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	25		25				25		25	25		25	25		25
H5216	252	0	1	04	01	H5216_252_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	25						25			25			25		25
H5216	253	0	1	04	01	H5216_253_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	0		0				25		25	0		0	0		0
H5216	253	0	1	04	01	H5216_253_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	25		25				25		25	25		0	25		25
H5216	253	0	1	04	01	H5216_253_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	25		25				25		25	25		25	25		25
H5216	253	0	1	04	01	H5216_253_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	25		25				25		25	25		25	25		25
H5216	253	0	1	04	01	H5216_253_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	25						25			25			25		25
H5216	261	0	1	04	01	H5216_261_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	0		0				25		25	0		0	0		0
H5216	261	0	1	04	01	H5216_261_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	25		25				25		25	25		0	25		25
H5216	261	0	1	04	01	H5216_261_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	25		25				25		25	25		25	25		25
H5216	261	0	1	04	01	H5216_261_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	46		46																								46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	261	0	1	04	01	H5216_261_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	25						25			25			25		25
H5216	263	0	1	04	01	H5216_263_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	0		0				25		25	0		0	0		0
H5216	263	0	1	04	01	H5216_263_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	25		25				25		25	25		0	25		25
H5216	263	0	1	04	01	H5216_263_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	25		25				25		25	25		25	25		25
H5216	263	0	1	04	01	H5216_263_0	3			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	25		25				25		25	25		25	25		25
H5216	263	0	1	04	01	H5216_263_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	25						25			25			25		25
H5216	264	0	1	04	01	H5216_264_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	0		0				25		25	0		0	0		0
H5216	264	0	1	04	01	H5216_264_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	0		0				25		25	0		0	0		0
H5216	264	0	1	04	01	H5216_264_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	25		25				25		25	25		25	25		25
H5216	264	0	1	04	01	H5216_264_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				30.00	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	25		25				25		25	25		25	25		25
H5216	264	0	1	04	01	H5216_264_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	25						25			25			25		25
H5216	265	0	1	04	01	H5216_265_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	0		0				25		25	0		0	0		0
H5216	265	0	1	04	01	H5216_265_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	265	0	1	04	01	H5216_265_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	25		25				25		25	25		25	25		25
H5216	265	0	1	04	01	H5216_265_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	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	25		25				25		25	25		25	25		25
H5216	265	0	1	04	01	H5216_265_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	25						25			25			25		25
H5216	266	0	1	04	01	H5216_266_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	0		0				25		25	0		0	0		0
H5216	266	0	1	04	01	H5216_266_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	266	0	1	04	01	H5216_266_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	25		25				25		25	25		25	25		25
H5216	266	0	1	04	01	H5216_266_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	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	25		25				25		25	25		25	25		25
H5216	266	0	1	04	01	H5216_266_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	25						25			25			25		25
H5216	267	0	1	04	01	H5216_267_0	5		N	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	0		0				25		25	0		0	0		0
H5216	267	0	1	04	01	H5216_267_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	0		0				25		25	0		0	0		0
H5216	267	0	1	04	01	H5216_267_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	267	0	1	04	01	H5216_267_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	267	0	1	04	01	H5216_267_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	25						25			25			25		25
H5216	268	0	1	04	01	H5216_268_0	5		N	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	0		0				25		25	0		0	0		0
H5216	268	0	1	04	01	H5216_268_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	0		0				25		25	0		0	0		0
H5216	268	0	1	04	01	H5216_268_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	268	0	1	04	01	H5216_268_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	268	0	1	04	01	H5216_268_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	25						25			25			25		25
H5216	269	0	1	04	01	H5216_269_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	0		0				25		25	0		0	0		0
H5216	269	0	1	04	01	H5216_269_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	269	0	1	04	01	H5216_269_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	25		25				25		25	25		25	25		25
H5216	269	0	1	04	01	H5216_269_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	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	25		25				25		25	25		25	25		25
H5216	269	0	1	04	01	H5216_269_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	25						25			25			25		25
H5216	271	0	1	04	01	H5216_271_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	0		0				25		25	0		0	0		0
H5216	271	0	1	04	01	H5216_271_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	271	0	1	04	01	H5216_271_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	25		25				25		25	25		25	25		25
H5216	271	0	1	04	01	H5216_271_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H5216	271	0	1	04	01	H5216_271_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	25						25			25			25		25
H5216	275	0	1	04	01	H5216_275_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	0		0				25		25	0		0	0		0
H5216	275	0	1	04	01	H5216_275_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	275	0	1	04	01	H5216_275_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	25		25				25		25	25		25	25		25
H5216	275	0	1	04	01	H5216_275_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	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	25		25				25		25	25		25	25		25
H5216	275	0	1	04	01	H5216_275_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	25						25			25			25		25
H5216	277	0	1	04	01	H5216_277_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	0		0				25		25	0		0	0		0
H5216	277	0	1	04	01	H5216_277_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	0		0				25		25	0		0	0		0
H5216	277	0	1	04	01	H5216_277_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	277	0	1	04	01	H5216_277_0	4		N	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	25		25				25		25	25		25	25		25
H5216	277	0	1	04	01	H5216_277_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	25						25			25			25		25
H5216	280	1	1	04	01	H5216_280_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																									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	0		0				25		25	0		0	0		0
H5216	280	1	1	04	01	H5216_280_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	280	1	1	04	01	H5216_280_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	25		25				25		25	25		25	25		25
H5216	280	1	1	04	01	H5216_280_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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	25		25				25		25	25		25	25		25
H5216	280	1	1	04	01	H5216_280_1	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	25						25			25			25		25
H5216	280	2	1	04	01	H5216_280_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																									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	0		0				25		25	0		0	0		0
H5216	280	2	1	04	01	H5216_280_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	280	2	1	04	01	H5216_280_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	25		25				25		25	25		25	25		25
H5216	280	2	1	04	01	H5216_280_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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	25		25				25		25	25		25	25		25
H5216	280	2	1	04	01	H5216_280_2	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	25						25			25			25		25
H5216	281	0	1	04	01	H5216_281_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	0		0				25		25	0		0	0		0
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	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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		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	25		25				25		25	25		25	25		25
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				94.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	283	0	1	04	01	H5216_283_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	0		0				25		25	0		0	0		0
H5216	283	0	1	04	01	H5216_283_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	283	0	1	04	01	H5216_283_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	25		25				25		25	25		25	25		25
H5216	283	0	1	04	01	H5216_283_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	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	25		25				25		25	25		25	25		25
H5216	283	0	1	04	01	H5216_283_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	25						25			25			25		25
H5216	284	0	1	04	01	H5216_284_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	0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5216	284	0	1	04	01	H5216_284_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	284	0	1	04	01	H5216_284_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	25		25				25		25	25		25	25		25
H5216	284	0	1	04	01	H5216_284_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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	25		25				25		25	25		25	25		25
H5216	284	0	1	04	01	H5216_284_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	25						25			25			25		25
H5216	285	0	1	04	01	H5216_285_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	0		0				25		25	0		0	0		0
H5216	285	0	1	04	01	H5216_285_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	285	0	1	04	01	H5216_285_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	25		25				25		25	25		25	25		25
H5216	285	0	1	04	01	H5216_285_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	285	0	1	04	01	H5216_285_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	25						25			25			25		25
H5216	287	0	1	04	01	H5216_287_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	0		0				25		25	0		0	0		0
H5216	287	0	1	04	01	H5216_287_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	287	0	1	04	01	H5216_287_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	25		25				25		25	25		25	25		25
H5216	287	0	1	04	01	H5216_287_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	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	25		25				25		25	25		25	25		25
H5216	287	0	1	04	01	H5216_287_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	25						25			25			25		25
H5216	288	0	1	04	01	H5216_288_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	0		0				25		25	0		0	0		0
H5216	288	0	1	04	01	H5216_288_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	288	0	1	04	01	H5216_288_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	25		25				25		25	25		25	25		25
H5216	288	0	1	04	01	H5216_288_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	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	25		25				25		25	25		25	25		25
H5216	288	0	1	04	01	H5216_288_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	25						25			25			25		25
H5216	289	0	1	04	01	H5216_289_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	0		0				25		25	0		0	0		0
H5216	289	0	1	04	01	H5216_289_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	289	0	1	04	01	H5216_289_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	25		25				25		25	25		25	25		25
H5216	289	0	1	04	01	H5216_289_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	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	25		25				25		25	25		25	25		25
H5216	289	0	1	04	01	H5216_289_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	25						25			25			25		25
H5216	291	0	1	04	01	H5216_291_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	0		0				25		25	0		0	0		0
H5216	291	0	1	04	01	H5216_291_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	0		0				25		25	0		0	0		0
H5216	291	0	1	04	01	H5216_291_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	291	0	1	04	01	H5216_291_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	291	0	1	04	01	H5216_291_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	25						25			25			25		25
H5216	292	0	1	04	01	H5216_292_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	0		0				25		25	0		0	0		0
H5216	292	0	1	04	01	H5216_292_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	0		0				25		25	0		0	0		0
H5216	292	0	1	04	01	H5216_292_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	292	0	1	04	01	H5216_292_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	292	0	1	04	01	H5216_292_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	25						25			25			25		25
H5216	296	0	1	04	01	H5216_296_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	0		0				25		25	0		0	0		0
H5216	296	0	1	04	01	H5216_296_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	0		0				25		25	0		0	0		0
H5216	296	0	1	04	01	H5216_296_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	296	0	1	04	01	H5216_296_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	296	0	1	04	01	H5216_296_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	25						25			25			25		25
H5216	298	0	1	04	01	H5216_298_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	0		0				25		25	0		0	0		0
H5216	298	0	1	04	01	H5216_298_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	0		0				25		25	0		0	0		0
H5216	298	0	1	04	01	H5216_298_0	5		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H5216	298	0	1	04	01	H5216_298_0	5		N	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	25		25				25		25	25		25	25		25
H5216	298	0	1	04	01	H5216_298_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	25						25			25			25		25
H5216	300	0	1	04	01	H5216_300_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																									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	0		0				25		25	0		0	0		0
H5216	300	0	1	04	01	H5216_300_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	300	0	1	04	01	H5216_300_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	25		25				25		25	25		25	25		25
H5216	300	0	1	04	01	H5216_300_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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	25		25				25		25	25		25	25		25
H5216	300	0	1	04	01	H5216_300_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	25						25			25			25		25
H5216	302	0	1	04	01	H5216_302_0	6		N	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	0		0				25		25	0		0	0		0
H5216	302	0	1	04	01	H5216_302_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	0		0				25		25	0		0	0		0
H5216	302	0	1	04	01	H5216_302_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	302	0	1	04	01	H5216_302_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	302	0	1	04	01	H5216_302_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	25						25			25			25		25
H5216	304	0	1	04	01	H5216_304_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	0		0				25		25	0		0	0		0
H5216	304	0	1	04	01	H5216_304_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	304	0	1	04	01	H5216_304_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	25		25				25		25	25		25	25		25
H5216	304	0	1	04	01	H5216_304_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	46		46																								46		46				46		46			46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	304	0	1	04	01	H5216_304_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	25						25			25			25		25
H5216	305	0	1	04	01	H5216_305_0	2			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	0		0				25		25	0		0	0		0
H5216	305	0	1	04	01	H5216_305_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	305	0	1	04	01	H5216_305_0	2			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	25		25				25		25	25		25	25		25
H5216	305	0	1	04	01	H5216_305_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				54.00	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	25		25				25		25	25		25	25		25
H5216	305	0	1	04	01	H5216_305_0	2			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	25						25			25			25		25
H5216	306	0	1	04	01	H5216_306_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	0		0				25		25	0		0	0		0
H5216	306	0	1	04	01	H5216_306_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	0		0				25		25	0		0	0		0
H5216	306	0	1	04	01	H5216_306_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	25		25				25		25	25		25	25		25
H5216	306	0	1	04	01	H5216_306_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H5216	306	0	1	04	01	H5216_306_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	25						25			25			25		25
H5216	307	0	1	04	01	H5216_307_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	0		0				25		25	0		0	0		0
H5216	307	0	1	04	01	H5216_307_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	25		25				25		25	25		0	25		25
H5216	307	0	1	04	01	H5216_307_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	25		25				25		25	25		25	25		25
H5216	307	0	1	04	01	H5216_307_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	307	0	1	04	01	H5216_307_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	25						25			25			25		25
H5216	308	0	1	04	01	H5216_308_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	0		0				25		25	0		0	0		0
H5216	308	0	1	04	01	H5216_308_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	308	0	1	04	01	H5216_308_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	25		25				25		25	25		25	25		25
H5216	308	0	1	04	01	H5216_308_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	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	25		25				25		25	25		25	25		25
H5216	308	0	1	04	01	H5216_308_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	25						25			25			25		25
H5216	309	0	1	04	01	H5216_309_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	0		0				25		25	0		0	0		0
H5216	309	0	1	04	01	H5216_309_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	0		0				25		25	0		0	0		0
H5216	309	0	1	04	01	H5216_309_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	25		25				25		25	25		25	25		25
H5216	309	0	1	04	01	H5216_309_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
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					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	311	0	1	04	01	H5216_311_0	2			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	0		0				25		25	0		0	0		0
H5216	311	0	1	04	01	H5216_311_0	2			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	25		25				25		25	25		0	25		25
H5216	311	0	1	04	01	H5216_311_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	311	0	1	04	01	H5216_311_0	2			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	25		25				25		25	25		25	25		25
H5216	311	0	1	04	01	H5216_311_0	2			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	25						25			25			25		25
H5216	313	0	1	04	01	H5216_313_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	0		0				25		25	0		0	0		0
H5216	313	0	1	04	01	H5216_313_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	25		25				25		25	25		0	25		25
H5216	313	0	1	04	01	H5216_313_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	25		25				25		25	25		25	25		25
H5216	313	0	1	04	01	H5216_313_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	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	25		25				25		25	25		25	25		25
H5216	313	0	1	04	01	H5216_313_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	25						25			25			25		25
H5216	314	0	1	04	01	H5216_314_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	0		0				25		25	0		0	0		0
H5216	314	0	1	04	01	H5216_314_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	25		25				25		25	25		0	25		25
H5216	314	0	1	04	01	H5216_314_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	25		25				25		25	25		25	25		25
H5216	314	0	1	04	01	H5216_314_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	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	25		25				25		25	25		25	25		25
H5216	314	0	1	04	01	H5216_314_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	25						25			25			25		25
H5216	316	1	1	04	01	H5216_316_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	0		0				25		25	0		0	0		0
H5216	316	1	1	04	01	H5216_316_1	3			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	25		25				25		25	25		0	25		25
H5216	316	1	1	04	01	H5216_316_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	25		25				25		25	25		25	25		25
H5216	316	1	1	04	01	H5216_316_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	316	1	1	04	01	H5216_316_1	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	25						25			25			25		25
H5216	316	3	1	04	01	H5216_316_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	0		0				25		25	0		0	0		0
H5216	316	3	1	04	01	H5216_316_3	3			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	25		25				25		25	25		0	25		25
H5216	316	3	1	04	01	H5216_316_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	25		25				25		25	25		25	25		25
H5216	316	3	1	04	01	H5216_316_3	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	316	3	1	04	01	H5216_316_3	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	25						25			25			25		25
H5216	317	0	1	04	01	H5216_317_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	0		0				25		25	0		0	0		0
H5216	317	0	1	04	01	H5216_317_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	317	0	1	04	01	H5216_317_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	25		25				25		25	25		25	25		25
H5216	317	0	1	04	01	H5216_317_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	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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	318	1	1	04	01	H5216_318_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	0		0				25		25	0		0	0		0
H5216	318	1	1	04	01	H5216_318_1	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	25		25				25		25	25		0	25		25
H5216	318	1	1	04	01	H5216_318_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	25		25				25		25	25		25	25		25
H5216	318	1	1	04	01	H5216_318_1	3			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	25		25				25		25	25		25	25		25
H5216	318	1	1	04	01	H5216_318_1	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	25						25			25			25		25
H5216	318	2	1	04	01	H5216_318_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	0		0				25		25	0		0	0		0
H5216	318	2	1	04	01	H5216_318_2	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	25		25				25		25	25		0	25		25
H5216	318	2	1	04	01	H5216_318_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	25		25				25		25	25		25	25		25
H5216	318	2	1	04	01	H5216_318_2	3			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	25		25				25		25	25		25	25		25
H5216	318	2	1	04	01	H5216_318_2	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	25						25			25			25		25
H5216	318	3	1	04	01	H5216_318_3	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	0		0				25		25	0		0	0		0
H5216	318	3	1	04	01	H5216_318_3	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	25		25				25		25	25		0	25		25
H5216	318	3	1	04	01	H5216_318_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	25		25				25		25	25		25	25		25
H5216	318	3	1	04	01	H5216_318_3	3			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	25		25				25		25	25		25	25		25
H5216	318	3	1	04	01	H5216_318_3	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	25						25			25			25		25
H5216	319	0	1	04	01	H5216_319_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	0		0				25		25	0		0	0		0
H5216	319	0	1	04	01	H5216_319_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	319	0	1	04	01	H5216_319_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	25		25				25		25	25		25	25		25
H5216	319	0	1	04	01	H5216_319_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				69.00	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	25		25				25		25	25		25	25		25
H5216	319	0	1	04	01	H5216_319_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	25						25			25			25		25
H5216	322	0	1	04	01	H5216_322_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	0		0				25		25	0		0	0		0
H5216	322	0	1	04	01	H5216_322_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00	25		25				25		25	25		0	25		25
H5216	322	0	1	04	01	H5216_322_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	25		25				25		25	25		25	25		25
H5216	322	0	1	04	01	H5216_322_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				56.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5216	325	0	1	04	01	H5216_325_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	0		0				25		25	0		0	0		0
H5216	325	0	1	04	01	H5216_325_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	325	0	1	04	01	H5216_325_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	25		25				25		25	25		25	25		25
H5216	325	0	1	04	01	H5216_325_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	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	25		25				25		25	25		25	25		25
H5216	325	0	1	04	01	H5216_325_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	25						25			25			25		25
H5216	326	0	1	04	01	H5216_326_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	0		0				25		25	0		0	0		0
H5216	326	0	1	04	01	H5216_326_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	326	0	1	04	01	H5216_326_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	25		25				25		25	25		25	25		25
H5216	326	0	1	04	01	H5216_326_0	3			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	25		25				25		25	25		25	25		25
H5216	326	0	1	04	01	H5216_326_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	25						25			25			25		25
H5216	327	0	1	04	01	H5216_327_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	0		0				25		25	0		0	0		0
H5216	327	0	1	04	01	H5216_327_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	327	0	1	04	01	H5216_327_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	25		25				25		25	25		25	25		25
H5216	327	0	1	04	01	H5216_327_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	327	0	1	04	01	H5216_327_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	25						25			25			25		25
H5216	328	0	1	04	01	H5216_328_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	0		0				25		25	0		0	0		0
H5216	328	0	1	04	01	H5216_328_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	328	0	1	04	01	H5216_328_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	25		25				25		25	25		25	25		25
H5216	328	0	1	04	01	H5216_328_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	330	0	1	04	01	H5216_330_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	0		0				25		25	0		0	0		0
H5216	330	0	1	04	01	H5216_330_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	0		0				25		25	0		0	0		0
H5216	330	0	1	04	01	H5216_330_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	330	0	1	04	01	H5216_330_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	330	0	1	04	01	H5216_330_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	25						25			25			25		25
H5216	331	0	1	04	01	H5216_331_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	0		0				25		25	0		0	0		0
H5216	331	0	1	04	01	H5216_331_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	0		0				25		25	0		0	0		0
H5216	331	0	1	04	01	H5216_331_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	331	0	1	04	01	H5216_331_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	331	0	1	04	01	H5216_331_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	25						25			25			25		25
H5216	332	0	1	04	01	H5216_332_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	0		0				25		25	0		0	0		0
H5216	332	0	1	04	01	H5216_332_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	0		0				25		25	0		0	0		0
H5216	332	0	1	04	01	H5216_332_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	332	0	1	04	01	H5216_332_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	332	0	1	04	01	H5216_332_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	25						25			25			25		25
H5216	333	0	1	04	01	H5216_333_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	0		0				25		25	0		0	0		0
H5216	333	0	1	04	01	H5216_333_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	25		25				25		25	25		0	25		25
H5216	333	0	1	04	01	H5216_333_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	25		25				25		25	25		25	25		25
H5216	333	0	1	04	01	H5216_333_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	25		25				25		25	25		25	25		25
H5216	333	0	1	04	01	H5216_333_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	25						25			25			25		25
H5216	334	0	1	04	01	H5216_334_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	0		0				25		25	0		0	0		0
H5216	334	0	1	04	01	H5216_334_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	25		25				25		25	25		0	25		25
H5216	334	0	1	04	01	H5216_334_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	334	0	1	04	01	H5216_334_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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	25		25				25		25	25		25	25		25
H5216	334	0	1	04	01	H5216_334_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	334	0	1	04	01	H5216_334_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	0		0				0		0	0		0	0		0
H5216	337	1	1	04	01	H5216_337_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	0		0				25		25	0		0	0		0
H5216	337	1	1	04	01	H5216_337_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	337	1	1	04	01	H5216_337_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	25		25				25		25	25		25	25		25
H5216	337	1	1	04	01	H5216_337_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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	25		25				25		25	25		25	25		25
H5216	337	1	1	04	01	H5216_337_1	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	25						25			25			25		25
H5216	337	2	1	04	01	H5216_337_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	0		0				25		25	0		0	0		0
H5216	337	2	1	04	01	H5216_337_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	337	2	1	04	01	H5216_337_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	25		25				25		25	25		25	25		25
H5216	337	2	1	04	01	H5216_337_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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	25		25				25		25	25		25	25		25
H5216	337	2	1	04	01	H5216_337_2	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	25						25			25			25		25
H5216	337	3	1	04	01	H5216_337_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	0		0				25		25	0		0	0		0
H5216	337	3	1	04	01	H5216_337_3	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	337	3	1	04	01	H5216_337_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	25		25				25		25	25		25	25		25
H5216	337	3	1	04	01	H5216_337_3	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				75.00	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	25		25				25		25	25		25	25		25
H5216	337	3	1	04	01	H5216_337_3	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	25						25			25			25		25
H5216	339	0	1	04	01	H5216_339_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	0		0				25		25	0		0	0		0
H5216	339	0	1	04	01	H5216_339_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	25		25				25		25	25		0	25		25
H5216	339	0	1	04	01	H5216_339_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	25		25				25		25	25		25	25		25
H5216	339	0	1	04	01	H5216_339_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	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	25		25				25		25	25		25	25		25
H5216	339	0	1	04	01	H5216_339_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	25						25			25			25		25
H5216	340	0	1	04	01	H5216_340_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	0		0				25		25	0		0	0		0
H5216	340	0	1	04	01	H5216_340_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	340	0	1	04	01	H5216_340_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	25		25				25		25	25		25	25		25
H5216	340	0	1	04	01	H5216_340_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	25		25				25		25	25		25	25		25
H5216	340	0	1	04	01	H5216_340_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	25						25			25			25		25
H5216	345	0	1	04	01	H5216_345_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	0		0				25		25	0		0	0		0
H5216	345	0	1	04	01	H5216_345_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	345	0	1	04	01	H5216_345_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	25		25				25		25	25		25	25		25
H5216	345	0	1	04	01	H5216_345_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	345	0	1	04	01	H5216_345_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	25						25			25			25		25
H5216	347	0	1	04	01	H5216_347_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	0		0				25		25	0		0	0		0
H5216	347	0	1	04	01	H5216_347_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	347	0	1	04	01	H5216_347_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	25		25				25		25	25		25	25		25
H5216	347	0	1	04	01	H5216_347_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	25		25				25		25	25		25	25		25
H5216	347	0	1	04	01	H5216_347_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	25						25			25			25		25
H5216	350	0	1	04	01	H5216_350_0	2			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	0		0				25		25	0		0	0		0
H5216	350	0	1	04	01	H5216_350_0	2			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	0		0				25		25	0		0	0		0
H5216	350	0	1	04	01	H5216_350_0	2			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	25		25				25		25	25		25	25		25
H5216	350	0	1	04	01	H5216_350_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				47.00	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	25		25				25		25	25		25	25		25
H5216	350	0	1	04	01	H5216_350_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	25						25			25			25		25
H5216	351	0	1	04	01	H5216_351_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	0		0				25		25	0		0	0		0
H5216	351	0	1	04	01	H5216_351_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	351	0	1	04	01	H5216_351_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	25		25				25		25	25		25	25		25
H5216	351	0	1	04	01	H5216_351_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	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	25		25				25		25	25		25	25		25
H5216	351	0	1	04	01	H5216_351_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	25						25			25			25		25
H5216	352	0	1	04	01	H5216_352_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	0		0				25		25	0		0	0		0
H5216	352	0	1	04	01	H5216_352_0	3			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	25		25				25		25	25		0	25		25
H5216	352	0	1	04	01	H5216_352_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	352	0	1	04	01	H5216_352_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	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	25		25				25		25	25		25	25		25
H5216	352	0	1	04	01	H5216_352_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	25						25			25			25		25
H5216	353	0	1	04	01	H5216_353_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	0		0				25		25	0		0	0		0
H5216	353	0	1	04	01	H5216_353_0	3			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	25		25				25		25	25		0	25		25
H5216	353	0	1	04	01	H5216_353_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	353	0	1	04	01	H5216_353_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	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	25		25				25		25	25		25	25		25
H5216	353	0	1	04	01	H5216_353_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	25						25			25			25		25
H5216	358	0	1	04	01	H5216_358_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	0		0				25		25	0		0	0		0
H5216	358	0	1	04	01	H5216_358_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	358	0	1	04	01	H5216_358_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	25		25				25		25	25		25	25		25
H5216	358	0	1	04	01	H5216_358_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
H5216	358	0	1	04	01	H5216_358_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	25						25			25			25		25
H5216	359	0	1	04	01	H5216_359_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	0		0				25		25	0		0	0		0
H5216	359	0	1	04	01	H5216_359_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	359	0	1	04	01	H5216_359_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	25		25				25		25	25		25	25		25
H5216	359	0	1	04	01	H5216_359_0	3			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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5216	360	0	1	04	01	H5216_360_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	0		0				25		25	0		0	0		0
H5216	360	0	1	04	01	H5216_360_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	360	0	1	04	01	H5216_360_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	360	0	1	04	01	H5216_360_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H5216	360	0	1	04	01	H5216_360_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	25						25			25			25		25
H5216	361	0	1	04	01	H5216_361_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	0		0				25		25	0		0	0		0
H5216	361	0	1	04	01	H5216_361_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	0		0				25		25	0		0	0		0
H5216	361	0	1	04	01	H5216_361_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	361	0	1	04	01	H5216_361_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	361	0	1	04	01	H5216_361_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	25						25			25			25		25
H5216	363	0	1	04	01	H5216_363_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	0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5216	363	0	1	04	01	H5216_363_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	363	0	1	04	01	H5216_363_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	25		25				25		25	25		25	25		25
H5216	363	0	1	04	01	H5216_363_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
H5216	363	0	1	04	01	H5216_363_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	25						25			25			25		25
H5216	366	0	1	04	01	H5216_366_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	0		0				25		25	0		0	0		0
H5216	366	0	1	04	01	H5216_366_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, Select Care Drugs	9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00	25		25				25		25	25		0	25		25
H5216	366	0	1	04	01	H5216_366_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	366	0	1	04	01	H5216_366_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	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H5216	366	0	1	04	01	H5216_366_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	0		0				0		0	0		0	0		0
H5216	367	0	1	04	01	H5216_367_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	0		0				25		25	0		0	0		0
H5216	367	0	1	04	01	H5216_367_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	0		0				25		25	0		0	0		0
H5216	367	0	1	04	01	H5216_367_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	367	0	1	04	01	H5216_367_0	5		N	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	25		25				25		25	25		25	25		25
H5216	367	0	1	04	01	H5216_367_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	25						25			25			25		25
H5216	368	0	1	04	01	H5216_368_0	2			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	0		0				25		25	0		0	0		0
H5216	368	0	1	04	01	H5216_368_0	2			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	25		25				25		25	25		0	25		25
H5216	368	0	1	04	01	H5216_368_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	368	0	1	04	01	H5216_368_0	2			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	25		25				25		25	25		25	25		25
H5216	368	0	1	04	01	H5216_368_0	2			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	25						25			25			25		25
H5216	369	0	1	04	01	H5216_369_0	2			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	0		0				25		25	0		0	0		0
H5216	369	0	1	04	01	H5216_369_0	2			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	0		0				25		25	0		0	0		0
H5216	369	0	1	04	01	H5216_369_0	2			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				24.00	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	25		25				25		25	25		25	25		25
H5216	369	0	1	04	01	H5216_369_0	2			Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	369	0	1	04	01	H5216_369_0	2			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	25						25			25			25		25
H5216	370	0	1	04	01	H5216_370_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	0		0				25		25	0		0	0		0
H5216	370	0	1	04	01	H5216_370_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	0		0				25		25	0		0	0		0
H5216	370	0	1	04	01	H5216_370_0	5		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H5216	370	0	1	04	01	H5216_370_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	370	0	1	04	01	H5216_370_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	25						25			25			25		25
H5216	371	0	1	04	01	H5216_371_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	0		0				25		25	0		0	0		0
H5216	371	0	1	04	01	H5216_371_0	3			Generic	4	11	1	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	25		25				25		25	25		0	25		25
H5216	371	0	1	04	01	H5216_371_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	25		25				25		25	25		25	25		25
H5216	371	0	1	04	01	H5216_371_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	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	25		25				25		25	25		25	25		25
H5216	371	0	1	04	01	H5216_371_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	25						25			25			25		25
H5216	372	0	1	04	01	H5216_372_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	0		0				25		25	0		0	0		0
H5216	372	0	1	04	01	H5216_372_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, Select Care Drugs	9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00	25		25				25		25	25		0	25		25
H5216	372	0	1	04	01	H5216_372_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	372	0	1	04	01	H5216_372_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
H5216	372	0	1	04	01	H5216_372_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	0		0				0		0	0		0	0		0
H5216	375	0	1	04	01	H5216_375_0	5			Preferred Generic	4	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5216	375	0	1	04	01	H5216_375_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	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	25		25				25		25	25		0	25		25
H5216	375	0	1	04	01	H5216_375_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	375	0	1	04	01	H5216_375_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	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	25		25				25		25	25		25	25		25
H5216	375	0	1	04	01	H5216_375_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H5216	375	0	1	04	01	H5216_375_0	5			Select Care Drugs	4	11	1	2	6	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									11.00		33.00				0.00		0.00				0.00				0.00		0.00				0.37	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00				11.00		33.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5216	376	0	1	04	01	H5216_376_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	0		0				0		0	0		0	0		0
H5216	376	0	1	04	01	H5216_376_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	376	0	1	04	01	H5216_376_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	25		25				25		25	25		25	25		25
H5216	376	0	1	04	01	H5216_376_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	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	25		25				25		25	25		25	25		25
H5216	376	0	1	04	01	H5216_376_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	25						25			25			25		25
H5216	377	0	1	04	01	H5216_377_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	0		0				25		25	0		0	0		0
H5216	377	0	1	04	01	H5216_377_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	0		0				25		25	0		0	0		0
H5216	377	0	1	04	01	H5216_377_0	5		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H5216	377	0	1	04	01	H5216_377_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	377	0	1	04	01	H5216_377_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	25						25			25			25		25
H5216	382	0	1	04	01	H5216_382_0	2			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	0		0				25		25	0		0	0		0
H5216	382	0	1	04	01	H5216_382_0	2			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	25		25				25		25	25		0	25		25
H5216	382	0	1	04	01	H5216_382_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	382	0	1	04	01	H5216_382_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
H5216	382	0	1	04	01	H5216_382_0	2			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	25						25			25			25		25
H5216	383	0	1	04	01	H5216_383_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	0		0				25		25	0		0	0		0
H5216	383	0	1	04	01	H5216_383_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	383	0	1	04	01	H5216_383_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	25		25				25		25	25		25	25		25
H5216	383	0	1	04	01	H5216_383_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5216	383	0	1	04	01	H5216_383_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	25						25			25			25		25
H5216	384	0	1	04	01	H5216_384_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	0		0				25		25	0		0	0		0
H5216	384	0	1	04	01	H5216_384_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	0		0				25		25	0		0	0		0
H5216	384	0	1	04	01	H5216_384_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	25		25				25		25	25		25	25		25
H5216	384	0	1	04	01	H5216_384_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5216	384	0	1	04	01	H5216_384_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	25						25			25			25		25
H5216	385	0	1	04	01	H5216_385_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	0		0				25		25	0		0	0		0
H5216	385	0	1	04	01	H5216_385_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	0		0				25		25	0		0	0		0
H5216	385	0	1	04	01	H5216_385_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	385	0	1	04	01	H5216_385_0	5		N	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	25		25				25		25	25		25	25		25
H5216	385	0	1	04	01	H5216_385_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	25						25			25			25		25
H5216	387	1	1	04	01	H5216_387_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	0		0				25		25	0		0	0		0
H5216	387	1	1	04	01	H5216_387_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	387	1	1	04	01	H5216_387_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	25		25				25		25	25		25	25		25
H5216	387	1	1	04	01	H5216_387_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	387	1	1	04	01	H5216_387_1	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	25						25			25			25		25
H5216	387	2	1	04	01	H5216_387_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	0		0				25		25	0		0	0		0
H5216	387	2	1	04	01	H5216_387_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	387	2	1	04	01	H5216_387_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	25		25				25		25	25		25	25		25
H5216	387	2	1	04	01	H5216_387_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	387	2	1	04	01	H5216_387_2	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	25						25			25			25		25
H5216	388	0	1	04	01	H5216_388_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	0		0				25		25	0		0	0		0
H5216	388	0	1	04	01	H5216_388_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	0		0				25		25	0		0	0		0
H5216	388	0	1	04	01	H5216_388_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	388	0	1	04	01	H5216_388_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	388	0	1	04	01	H5216_388_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	25						25			25			25		25
H5216	389	0	1	04	01	H5216_389_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	0		0				25		25	0		0	0		0
H5216	389	0	1	04	01	H5216_389_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	389	0	1	04	01	H5216_389_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	25		25				25		25	25		25	25		25
H5216	389	0	1	04	01	H5216_389_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	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	25		25				25		25	25		25	25		25
H5216	389	0	1	04	01	H5216_389_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	25						25			25			25		25
H5216	390	0	1	04	01	H5216_390_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	0		0				25		25	0		0	0		0
H5216	390	0	1	04	01	H5216_390_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	390	0	1	04	01	H5216_390_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	25		25				25		25	25		25	25		25
H5216	390	0	1	04	01	H5216_390_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	390	0	1	04	01	H5216_390_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	25						25			25			25		25
H5216	391	0	1	04	01	H5216_391_0	2			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	0		0				25		25	0		0	0		0
H5216	391	0	1	04	01	H5216_391_0	2			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	25		25				25		25	25		0	25		25
H5216	391	0	1	04	01	H5216_391_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	391	0	1	04	01	H5216_391_0	2			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	25		25				25		25	25		25	25		25
H5216	391	0	1	04	01	H5216_391_0	2			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	25						25			25			25		25
H5216	393	0	1	04	01	H5216_393_0	2			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	0		0				25		25	0		0	0		0
H5216	393	0	1	04	01	H5216_393_0	2			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	25		25				25		25	25		0	25		25
H5216	393	0	1	04	01	H5216_393_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	393	0	1	04	01	H5216_393_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5216	393	0	1	04	01	H5216_393_0	2			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	25						25			25			25		25
H5216	394	0	1	04	01	H5216_394_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	0		0				25		25	0		0	0		0
H5216	394	0	1	04	01	H5216_394_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	0		0				25		25	0		0	0		0
H5216	394	0	1	04	01	H5216_394_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	394	0	1	04	01	H5216_394_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	394	0	1	04	01	H5216_394_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	25						25			25			25		25
H5216	395	0	1	04	01	H5216_395_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	0		0				25		25	0		0	0		0
H5216	395	0	1	04	01	H5216_395_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	395	0	1	04	01	H5216_395_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	25		25				25		25	25		25	25		25
H5216	395	0	1	04	01	H5216_395_0	3			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	25		25				25		25	25		25	25		25
H5216	395	0	1	04	01	H5216_395_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	25						25			25			25		25
H5216	396	0	1	04	01	H5216_396_0	2			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	0		0				25		25	0		0	0		0
H5216	396	0	1	04	01	H5216_396_0	2			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	25		25				25		25	25		0	25		25
H5216	396	0	1	04	01	H5216_396_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	396	0	1	04	01	H5216_396_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				66.00	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	25		25				25		25	25		25	25		25
H5216	396	0	1	04	01	H5216_396_0	2			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	25						25			25			25		25
H5216	399	0	1	04	01	H5216_399_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	0		0				25		25	0		0	0		0
H5216	399	0	1	04	01	H5216_399_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	399	0	1	04	01	H5216_399_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	25		25				25		25	25		25	25		25
H5216	399	0	1	04	01	H5216_399_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	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	25		25				25		25	25		25	25		25
H5216	399	0	1	04	01	H5216_399_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	25						25			25			25		25
H5216	403	0	1	04	01	H5216_403_0	2			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	0		0				25		25	0		0	0		0
H5216	403	0	1	04	01	H5216_403_0	2			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	25		25				25		25	25		0	25		25
H5216	403	0	1	04	01	H5216_403_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	403	0	1	04	01	H5216_403_0	2			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	25		25				25		25	25		25	25		25
H5216	403	0	1	04	01	H5216_403_0	2			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	25						25			25			25		25
H5216	404	0	1	04	01	H5216_404_0	2			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	0		0				25		25	0		0	0		0
H5216	404	0	1	04	01	H5216_404_0	2			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	25		25				25		25	25		0	25		25
H5216	404	0	1	04	01	H5216_404_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	404	0	1	04	01	H5216_404_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				79.00	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	25		25				25		25	25		25	25		25
H5216	404	0	1	04	01	H5216_404_0	2			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	25						25			25			25		25
H5216	405	0	1	04	01	H5216_405_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	0		0				25		25	0		0	0		0
H5216	405	0	1	04	01	H5216_405_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	25		25				25		25	25		0	25		25
H5216	405	0	1	04	01	H5216_405_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	25		25				25		25	25		25	25		25
H5216	405	0	1	04	01	H5216_405_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	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	25		25				25		25	25		25	25		25
H5216	405	0	1	04	01	H5216_405_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	25						25			25			25		25
H5216	406	0	1	04	01	H5216_406_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	0		0				25		25	0		0	0		0
H5216	406	0	1	04	01	H5216_406_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	0		0				25		25	0		0	0		0
H5216	406	0	1	04	01	H5216_406_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	25		25				25		25	25		25	25		25
H5216	406	0	1	04	01	H5216_406_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	406	0	1	04	01	H5216_406_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	25						25			25			25		25
H5216	407	0	1	04	01	H5216_407_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	0		0				25		25	0		0	0		0
H5216	407	0	1	04	01	H5216_407_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	25		25				25		25	25		0	25		25
H5216	407	0	1	04	01	H5216_407_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	25		25				25		25	25		25	25		25
H5216	407	0	1	04	01	H5216_407_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	407	0	1	04	01	H5216_407_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	25						25			25			25		25
H5216	408	0	1	04	01	H5216_408_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	0		0				25		25	0		0	0		0
H5216	408	0	1	04	01	H5216_408_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	0		0				25		25	0		0	0		0
H5216	408	0	1	04	01	H5216_408_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	25		25				25		25	25		25	25		25
H5216	408	0	1	04	01	H5216_408_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	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	25		25				25		25	25		25	25		25
H5216	408	0	1	04	01	H5216_408_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	25						25			25			25		25
H5216	409	0	1	04	01	H5216_409_0	2			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	0		0				25		25	0		0	0		0
H5216	409	0	1	04	01	H5216_409_0	2			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	25		25				25		25	25		0	25		25
H5216	409	0	1	04	01	H5216_409_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	409	0	1	04	01	H5216_409_0	2			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	25		25				25		25	25		25	25		25
H5216	409	0	1	04	01	H5216_409_0	2			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	25						25			25			25		25
H5216	410	0	1	04	01	H5216_410_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	0		0				25		25	0		0	0		0
H5216	410	0	1	04	01	H5216_410_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	25		25				25		25	25		0	25		25
H5216	410	0	1	04	01	H5216_410_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	25		25				25		25	25		25	25		25
H5216	410	0	1	04	01	H5216_410_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	410	0	1	04	01	H5216_410_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	25						25			25			25		25
H5216	411	0	1	04	01	H5216_411_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	0		0				25		25	0		0	0		0
H5216	411	0	1	04	01	H5216_411_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	411	0	1	04	01	H5216_411_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	25		25				25		25	25		25	25		25
H5216	411	0	1	04	01	H5216_411_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5216	411	0	1	04	01	H5216_411_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	25						25			25			25		25
H5216	412	0	1	04	01	H5216_412_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	0		0				25		25	0		0	0		0
H5216	412	0	1	04	01	H5216_412_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	25		25				25		25	25		0	25		25
H5216	412	0	1	04	01	H5216_412_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	25		25				25		25	25		25	25		25
H5216	412	0	1	04	01	H5216_412_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	25		25				25		25	25		25	25		25
H5216	412	0	1	04	01	H5216_412_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	25						25			25			25		25
H5216	414	0	1	04	01	H5216_414_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	0		0				25		25	0		0	0		0
H5216	414	0	1	04	01	H5216_414_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5216	414	0	1	04	01	H5216_414_0	4			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	414	0	1	04	01	H5216_414_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				49.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5216	414	0	1	04	01	H5216_414_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	0		0				0		0	0		0	0		0
H5216	416	0	1	04	01	H5216_416_0	2			Preferred Generic	4	11	1	1	1	1	110		01		110	1	30		100				1	2				30		100	30		31				2.00	18		18																								25		25				18		0			18			18								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	18		18				25		25	18		0	18		18
H5216	416	0	1	04	01	H5216_416_0	2			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	25		25				25		25	25		0	25		25
H5216	416	0	1	04	01	H5216_416_0	2			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				24.00	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	25		25				25		25	25		25	25		25
H5216	416	0	1	04	01	H5216_416_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	416	0	1	04	01	H5216_416_0	2			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	25						25			25			25		25
H5216	417	0	1	04	01	H5216_417_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	0		0				25		25	0		0	0		0
H5216	417	0	1	04	01	H5216_417_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	417	0	1	04	01	H5216_417_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	25		25				25		25	25		25	25		25
H5216	417	0	1	04	01	H5216_417_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	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	25		25				25		25	25		25	25		25
H5216	417	0	1	04	01	H5216_417_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	25						25			25			25		25
H5216	420	0	1	04	01	H5216_420_0	5		N	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	0		0				25		25	0		0	0		0
H5216	420	0	1	04	01	H5216_420_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	0		0				25		25	0		0	0		0
H5216	420	0	1	04	01	H5216_420_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	420	0	1	04	01	H5216_420_0	5		N	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	25		25				25		25	25		25	25		25
H5216	420	0	1	04	01	H5216_420_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	25						25			25			25		25
H5216	421	0	1	04	01	H5216_421_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	0		0				25		25	0		0	0		0
H5216	421	0	1	04	01	H5216_421_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	0		0				25		25	0		0	0		0
H5216	421	0	1	04	01	H5216_421_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	25		25				25		25	25		25	25		25
H5216	421	0	1	04	01	H5216_421_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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	25		25				25		25	25		25	25		25
H5216	421	0	1	04	01	H5216_421_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	25						25			25			25		25
H5216	423	0	1	04	01	H5216_423_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	0		0				25		25	0		0	0		0
H5216	423	0	1	04	01	H5216_423_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	0		0				25		25	0		0	0		0
H5216	423	0	1	04	01	H5216_423_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	25		25				25		25	25		25	25		25
H5216	423	0	1	04	01	H5216_423_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	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	25		25				25		25	25		25	25		25
H5216	423	0	1	04	01	H5216_423_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	25						25			25			25		25
H5216	424	0	1	04	01	H5216_424_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	0		0				25		25	0		0	0		0
H5216	424	0	1	04	01	H5216_424_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	424	0	1	04	01	H5216_424_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	25		25				25		25	25		25	25		25
H5216	424	0	1	04	01	H5216_424_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	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	25		25				25		25	25		25	25		25
H5216	424	0	1	04	01	H5216_424_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	25						25			25			25		25
H5216	425	0	1	04	01	H5216_425_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	0		0				25		25	0		0	0		0
H5216	425	0	1	04	01	H5216_425_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	425	0	1	04	01	H5216_425_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	25		25				25		25	25		25	25		25
H5216	425	0	1	04	01	H5216_425_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	425	0	1	04	01	H5216_425_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	25						25			25			25		25
H5216	426	0	1	04	01	H5216_426_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	0		0				25		25	0		0	0		0
H5216	426	0	1	04	01	H5216_426_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	25		25				25		25	25		0	25		25
H5216	426	0	1	04	01	H5216_426_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	25		25				25		25	25		25	25		25
H5216	426	0	1	04	01	H5216_426_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	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	25		25				25		25	25		25	25		25
H5216	426	0	1	04	01	H5216_426_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	25						25			25			25		25
H5216	428	1	1	04	01	H5216_428_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	0		0				25		25	0		0	0		0
H5216	428	1	1	04	01	H5216_428_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	25		25				25		25	25		0	25		25
H5216	428	1	1	04	01	H5216_428_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	25		25				25		25	25		25	25		25
H5216	428	1	1	04	01	H5216_428_1	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	25		25				25		25	25		25	25		25
H5216	428	1	1	04	01	H5216_428_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	25						25			25			25		25
H5216	428	2	1	04	01	H5216_428_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	0		0				25		25	0		0	0		0
H5216	428	2	1	04	01	H5216_428_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	25		25				25		25	25		0	25		25
H5216	428	2	1	04	01	H5216_428_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	25		25				25		25	25		25	25		25
H5216	428	2	1	04	01	H5216_428_2	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	25		25				25		25	25		25	25		25
H5216	428	2	1	04	01	H5216_428_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	25						25			25			25		25
H5216	428	3	1	04	01	H5216_428_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	0		0				25		25	0		0	0		0
H5216	428	3	1	04	01	H5216_428_3	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	25		25				25		25	25		0	25		25
H5216	428	3	1	04	01	H5216_428_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	25		25				25		25	25		25	25		25
H5216	428	3	1	04	01	H5216_428_3	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	25		25				25		25	25		25	25		25
H5216	428	3	1	04	01	H5216_428_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	25						25			25			25		25
H5216	428	5	1	04	01	H5216_428_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	0		0				25		25	0		0	0		0
H5216	428	5	1	04	01	H5216_428_5	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	25		25				25		25	25		0	25		25
H5216	428	5	1	04	01	H5216_428_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	25		25				25		25	25		25	25		25
H5216	428	5	1	04	01	H5216_428_5	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	25		25				25		25	25		25	25		25
H5216	428	5	1	04	01	H5216_428_5	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	25						25			25			25		25
H5216	429	0	1	04	01	H5216_429_0	2			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	0		0				25		25	0		0	0		0
H5216	429	0	1	04	01	H5216_429_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	429	0	1	04	01	H5216_429_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	429	0	1	04	01	H5216_429_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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	25		25				25		25	25		25	25		25
H5216	429	0	1	04	01	H5216_429_0	2			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	25						25			25			25		25
H5216	430	0	1	04	01	H5216_430_0	2			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	0		0				25		25	0		0	0		0
H5216	430	0	1	04	01	H5216_430_0	2			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	25		25				25		25	25		0	25		25
H5216	430	0	1	04	01	H5216_430_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	430	0	1	04	01	H5216_430_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
H5216	430	0	1	04	01	H5216_430_0	2			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	25						25			25			25		25
H5216	431	0	1	04	01	H5216_431_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	0		0				25		25	0		0	0		0
H5216	431	0	1	04	01	H5216_431_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	431	0	1	04	01	H5216_431_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	25		25				25		25	25		25	25		25
H5216	431	0	1	04	01	H5216_431_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
H5216	431	0	1	04	01	H5216_431_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	25						25			25			25		25
H5216	432	0	1	04	01	H5216_432_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	0		0				25		25	0		0	0		0
H5216	432	0	1	04	01	H5216_432_0	3			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	25		25				25		25	25		0	25		25
H5216	432	0	1	04	01	H5216_432_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	25		25				25		25	25		25	25		25
H5216	432	0	1	04	01	H5216_432_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	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	25		25				25		25	25		25	25		25
H5216	432	0	1	04	01	H5216_432_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	25						25			25			25		25
H5216	433	0	1	04	01	H5216_433_0	2			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	0		0				25		25	0		0	0		0
H5216	433	0	1	04	01	H5216_433_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	433	0	1	04	01	H5216_433_0	2			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	25		25				25		25	25		25	25		25
H5216	433	0	1	04	01	H5216_433_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				57.00	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	25		25				25		25	25		25	25		25
H5216	433	0	1	04	01	H5216_433_0	2			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	25						25			25			25		25
H5216	435	1	1	04	01	H5216_435_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	0		0				25		25	0		0	0		0
H5216	435	1	1	04	01	H5216_435_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	0		0				25		25	0		0	0		0
H5216	435	1	1	04	01	H5216_435_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	25		25				25		25	25		25	25		25
H5216	435	1	1	04	01	H5216_435_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				27.00	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	25		25				25		25	25		25	25		25
H5216	435	1	1	04	01	H5216_435_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	25						25			25			25		25
H5216	435	2	1	04	01	H5216_435_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	0		0				25		25	0		0	0		0
H5216	435	2	1	04	01	H5216_435_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	0		0				25		25	0		0	0		0
H5216	435	2	1	04	01	H5216_435_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	25		25				25		25	25		25	25		25
H5216	435	2	1	04	01	H5216_435_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				27.00	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	25		25				25		25	25		25	25		25
H5216	435	2	1	04	01	H5216_435_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	25						25			25			25		25
H5216	435	3	1	04	01	H5216_435_3	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	0		0				25		25	0		0	0		0
H5216	435	3	1	04	01	H5216_435_3	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	0		0				25		25	0		0	0		0
H5216	435	3	1	04	01	H5216_435_3	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	25		25				25		25	25		25	25		25
H5216	435	3	1	04	01	H5216_435_3	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				27.00	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	25		25				25		25	25		25	25		25
H5216	435	3	1	04	01	H5216_435_3	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5216	443	0	1	04	01	H5216_443_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	0		0				25		25	0		0	0		0
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	0.00		0.00																									20.00		60.00				0.00		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	0		0				25		25	0		0	0		0
H5216	443	0	1	04	01	H5216_443_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	443	0	1	04	01	H5216_443_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				49.00	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	25		25				25		25	25		25	25		25
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					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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
H5216	444	0	1	04	01	H5216_444_0	2			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	0		0				25		25	0		0	0		0
H5216	444	0	1	04	01	H5216_444_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	444	0	1	04	01	H5216_444_0	2			Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				24.00	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	25		25				25		25	25		25	25		25
H5216	444	0	1	04	01	H5216_444_0	2			Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	444	0	1	04	01	H5216_444_0	2			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	25						25			25			25		25
H5216	448	0	1	04	01	H5216_448_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	0		0				25		25	0		0	0		0
H5216	448	0	1	04	01	H5216_448_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	448	0	1	04	01	H5216_448_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	25		25				25		25	25		25	25		25
H5216	448	0	1	04	01	H5216_448_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	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	25		25				25		25	25		25	25		25
H5216	448	0	1	04	01	H5216_448_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	25						25			25			25		25
H5216	449	0	1	04	01	H5216_449_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	0		0				25		25	0		0	0		0
H5216	449	0	1	04	01	H5216_449_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	449	0	1	04	01	H5216_449_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	25		25				25		25	25		25	25		25
H5216	449	0	1	04	01	H5216_449_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	25		25				25		25	25		25	25		25
H5216	449	0	1	04	01	H5216_449_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	25						25			25			25		25
H5216	450	0	1	04	01	H5216_450_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	0		0				25		25	0		0	0		0
H5216	450	0	1	04	01	H5216_450_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	450	0	1	04	01	H5216_450_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	25		25				25		25	25		25	25		25
H5216	450	0	1	04	01	H5216_450_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	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	25		25				25		25	25		25	25		25
H5216	450	0	1	04	01	H5216_450_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	25						25			25			25		25
H5216	451	0	1	04	01	H5216_451_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	0		0				25		25	0		0	0		0
H5216	451	0	1	04	01	H5216_451_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	451	0	1	04	01	H5216_451_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	25		25				25		25	25		25	25		25
H5216	451	0	1	04	01	H5216_451_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	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	25		25				25		25	25		25	25		25
H5216	451	0	1	04	01	H5216_451_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	25						25			25			25		25
H5216	452	0	1	04	01	H5216_452_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	0		0				25		25	0		0	0		0
H5216	452	0	1	04	01	H5216_452_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5216	452	0	1	04	01	H5216_452_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	25		25				25		25	25		25	25		25
H5216	452	0	1	04	01	H5216_452_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	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	25		25				25		25	25		25	25		25
H5216	452	0	1	04	01	H5216_452_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	25						25			25			25		25
H5216	453	0	1	04	01	H5216_453_0	2			Preferred Generic	4	11	1	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	25		25				25		25	25		0	25		25
H5216	453	0	1	04	01	H5216_453_0	2			Generic	4	11	1	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	25		25				25		25	25		0	25		25
H5216	453	0	1	04	01	H5216_453_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5216	453	0	1	04	01	H5216_453_0	2			Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	453	0	1	04	01	H5216_453_0	2			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	25						25			25			25		25
H5216	456	1	1	04	01	H5216_456_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	0		0				25		25	0		0	0		0
H5216	456	1	1	04	01	H5216_456_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	456	1	1	04	01	H5216_456_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	25		25				25		25	25		25	25		25
H5216	456	1	1	04	01	H5216_456_1	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	25		25				25		25	25		25	25		25
H5216	456	1	1	04	01	H5216_456_1	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	25						25			25			25		25
H5216	456	2	1	04	01	H5216_456_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	0		0				25		25	0		0	0		0
H5216	456	2	1	04	01	H5216_456_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	456	2	1	04	01	H5216_456_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	25		25				25		25	25		25	25		25
H5216	456	2	1	04	01	H5216_456_2	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	25		25				25		25	25		25	25		25
H5216	456	2	1	04	01	H5216_456_2	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	25						25			25			25		25
H5216	457	1	1	04	01	H5216_457_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	0		0				25		25	0		0	0		0
H5216	457	1	1	04	01	H5216_457_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	457	1	1	04	01	H5216_457_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	25		25				25		25	25		25	25		25
H5216	457	1	1	04	01	H5216_457_1	3			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	25		25				25		25	25		25	25		25
H5216	457	1	1	04	01	H5216_457_1	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	25						25			25			25		25
H5216	457	2	1	04	01	H5216_457_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	0		0				25		25	0		0	0		0
H5216	457	2	1	04	01	H5216_457_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	457	2	1	04	01	H5216_457_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	25		25				25		25	25		25	25		25
H5216	457	2	1	04	01	H5216_457_2	3			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	25		25				25		25	25		25	25		25
H5216	457	2	1	04	01	H5216_457_2	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	25						25			25			25		25
H5216	459	0	1	04	01	H5216_459_0	3		N	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	0		0				25		25	0		0	0		0
H5216	459	0	1	04	01	H5216_459_0	3		N	Generic	4	11	1	1	2	1	110		01		110	1	30		100				2	2				30		100	30		31				0.00	5		5																								25		25				5		0			5			5								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	5		5				25		25	5		0	5		5
H5216	459	0	1	04	01	H5216_459_0	3		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	459	0	1	04	01	H5216_459_0	3		N	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	25		25				25		25	25		25	25		25
H5216	459	0	1	04	01	H5216_459_0	3		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	25						25			25			25		25
H5216	461	0	1	04	01	H5216_461_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	0		0				25		25	0		0	0		0
H5216	461	0	1	04	01	H5216_461_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	461	0	1	04	01	H5216_461_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	25		25				25		25	25		25	25		25
H5216	461	0	1	04	01	H5216_461_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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	25		25				25		25	25		25	25		25
H5216	461	0	1	04	01	H5216_461_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	25						25			25			25		25
H5216	463	0	1	04	01	H5216_463_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	0		0				25		25	0		0	0		0
H5216	463	0	1	04	01	H5216_463_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	25		25				25		25	25		0	25		25
H5216	463	0	1	04	01	H5216_463_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	25		25				25		25	25		25	25		25
H5216	463	0	1	04	01	H5216_463_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	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	25		25				25		25	25		25	25		25
H5216	463	0	1	04	01	H5216_463_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	25						25			25			25		25
H5216	464	0	1	04	01	H5216_464_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	0		0				25		25	0		0	0		0
H5216	464	0	1	04	01	H5216_464_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	25		25				25		25	25		0	25		25
H5216	464	0	1	04	01	H5216_464_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	25		25				25		25	25		25	25		25
H5216	464	0	1	04	01	H5216_464_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	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	25		25				25		25	25		25	25		25
H5216	464	0	1	04	01	H5216_464_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	25						25			25			25		25
H5216	465	0	1	04	01	H5216_465_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	0		0				25		25	0		0	0		0
H5216	465	0	1	04	01	H5216_465_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	465	0	1	04	01	H5216_465_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	25		25				25		25	25		25	25		25
H5216	465	0	1	04	01	H5216_465_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	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	25		25				25		25	25		25	25		25
H5216	465	0	1	04	01	H5216_465_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	25						25			25			25		25
H5216	466	0	1	04	01	H5216_466_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	0		0				25		25	0		0	0		0
H5216	466	0	1	04	01	H5216_466_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5216	466	0	1	04	01	H5216_466_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	25		25				25		25	25		25	25		25
H5216	466	0	1	04	01	H5216_466_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	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	25		25				25		25	25		25	25		25
H5216	466	0	1	04	01	H5216_466_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	25						25			25			25		25
H5216	468	0	1	04	01	H5216_468_0	4		N	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	0		0				25		25	0		0	0		0
H5216	468	0	1	04	01	H5216_468_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	0		0				25		25	0		0	0		0
H5216	468	0	1	04	01	H5216_468_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	468	0	1	04	01	H5216_468_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5216	468	0	1	04	01	H5216_468_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	25						25			25			25		25
H5216	469	0	1	04	01	H5216_469_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	0		0				25		25	0		0	0		0
H5216	469	0	1	04	01	H5216_469_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	0		0				25		25	0		0	0		0
H5216	469	0	1	04	01	H5216_469_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	469	0	1	04	01	H5216_469_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	469	0	1	04	01	H5216_469_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	25						25			25			25		25
H5216	470	0	1	04	01	H5216_470_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	0		0				25		25	0		0	0		0
H5216	470	0	1	04	01	H5216_470_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	0		0				25		25	0		0	0		0
H5216	470	0	1	04	01	H5216_470_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5216	470	0	1	04	01	H5216_470_0	4		N	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	25		25				25		25	25		25	25		25
H5216	470	0	1	04	01	H5216_470_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	25						25			25			25		25
H5232	001	0	1	04	01	H5232_001_0	18			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	25		25				25		25				25		25
H5232	001	0	1	04	01	H5232_001_0	18			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	25		25				25		25				25		25
H5232	001	0	1	04	01	H5232_001_0	18			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				35.81	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		35.00	21		21				21		21				21		21
H5232	001	0	1	04	01	H5232_001_0	18			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				73.31	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		35.00	25		25				25		25				25		25
H5232	001	0	1	04	01	H5232_001_0	18			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				304.84	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5244	001	0	1	01	01	H5244_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	0.00				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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5244	001	0	1	01	01	H5244_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								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5244	001	0	1	01	01	H5244_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											44.45	35	35	35				44.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5244	001	0	1	01	01	H5244_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5244	002	0	1	01	01	H5244_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	0.00				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	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	002	0	1	01	01	H5244_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								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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5244	002	0	1	01	01	H5244_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											51.77	35	35	35				51.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5244	002	0	1	01	01	H5244_002_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																														
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											102.35	25	25	25				102.35	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											59.83	30	30	30				59.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	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																														
H5244	005	0	1	01	01	H5244_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																														
H5244	005	0	1	01	01	H5244_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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5244	005	0	1	01	01	H5244_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											45.80	35	35	35				45.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5244	005	0	1	01	01	H5244_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																														
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		0.17						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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	004	0	1	02	01	H5253_004_0	8			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				395.00	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	25						25			25			25		25
H5253	011	0	1	02	01	H5253_011_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	011	0	1	02	01	H5253_011_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	011	0	1	02	01	H5253_011_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	011	0	1	02	01	H5253_011_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	011	0	1	02	01	H5253_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				379.00	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	25						25			25			25		25
H5253	024	0	1	02	01	H5253_024_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5253	024	0	1	02	01	H5253_024_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	024	0	1	02	01	H5253_024_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H5253	024	0	1	02	01	H5253_024_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	024	0	1	02	01	H5253_024_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				354.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	030	0	1	02	01	H5253_030_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																														
H5253	030	0	1	02	01	H5253_030_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						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	030	0	1	02	01	H5253_030_0	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	030	0	1	02	01	H5253_030_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	030	0	1	02	01	H5253_030_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				345.00	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	033	0	1	02	01	H5253_033_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	033	0	1	02	01	H5253_033_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	033	0	1	02	01	H5253_033_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	033	0	1	02	01	H5253_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				98.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	033	0	1	02	01	H5253_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				341.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	034	0	1	02	01	H5253_034_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	034	0	1	02	01	H5253_034_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	034	0	1	02	01	H5253_034_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	034	0	1	02	01	H5253_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	034	0	1	02	01	H5253_034_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H5253	035	0	1	02	01	H5253_035_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	035	0	1	02	01	H5253_035_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	035	0	1	02	01	H5253_035_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	035	0	1	02	01	H5253_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	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	25						25			25			25		25
H5253	035	0	1	02	01	H5253_035_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H5253	036	0	1	02	01	H5253_036_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	036	0	1	02	01	H5253_036_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	036	0	1	02	01	H5253_036_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	036	0	1	02	01	H5253_036_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	036	0	1	02	01	H5253_036_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				333.00	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	25						25			25			25		25
H5253	037	0	1	02	01	H5253_037_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	037	0	1	02	01	H5253_037_0	5			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	037	0	1	02	01	H5253_037_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H5253	037	0	1	02	01	H5253_037_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	037	0	1	02	01	H5253_037_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				410.00	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	25						25			25			25		25
H5253	038	0	1	02	01	H5253_038_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	038	0	1	02	01	H5253_038_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	038	0	1	02	01	H5253_038_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	038	0	1	02	01	H5253_038_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	038	0	1	02	01	H5253_038_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				417.00	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	25						25			25			25		25
H5253	039	0	1	02	01	H5253_039_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	039	0	1	02	01	H5253_039_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	039	0	1	02	01	H5253_039_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	039	0	1	02	01	H5253_039_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	039	0	1	02	01	H5253_039_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				377.00	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	25						25			25			25		25
H5253	041	0	1	02	01	H5253_041_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5253	041	0	1	02	01	H5253_041_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	041	0	1	02	01	H5253_041_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H5253	041	0	1	02	01	H5253_041_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	041	0	1	02	01	H5253_041_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	047	0	1	02	01	H5253_047_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	047	0	1	02	01	H5253_047_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	047	0	1	02	01	H5253_047_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	047	0	1	02	01	H5253_047_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	047	0	1	02	01	H5253_047_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	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	25						25			25			25		25
H5253	048	0	1	02	01	H5253_048_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	048	0	1	02	01	H5253_048_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	048	0	1	02	01	H5253_048_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H5253	048	0	1	02	01	H5253_048_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	048	0	1	02	01	H5253_048_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	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	25						25			25			25		25
H5253	051	0	1	02	01	H5253_051_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	051	0	1	02	01	H5253_051_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	051	0	1	02	01	H5253_051_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H5253	051	0	1	02	01	H5253_051_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	051	0	1	02	01	H5253_051_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				432.00	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	25						25			25			25		25
H5253	059	0	1	01	01	H5253_059_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H5253	059	0	1	01	01	H5253_059_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	059	0	1	01	01	H5253_059_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	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	25		25						25				25		25
H5253	059	0	1	01	01	H5253_059_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5253	059	0	1	01	01	H5253_059_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	062	0	1	02	01	H5253_062_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	062	0	1	02	01	H5253_062_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	062	0	1	02	01	H5253_062_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	062	0	1	02	01	H5253_062_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	062	0	1	02	01	H5253_062_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				366.00	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	25						25			25			25		25
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	0.00		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	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						0.39	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				54.00	25		25																										25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	25		25						25			25	25		25
H5253	064	0	1	02	01	H5253_064_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	50																										50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				408.00	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	25						25			25			25		25
H5253	072	0	1	02	01	H5253_072_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																														
H5253	072	0	1	02	01	H5253_072_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	072	0	1	02	01	H5253_072_0	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	072	0	1	02	01	H5253_072_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	072	0	1	02	01	H5253_072_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	079	0	1	02	01	H5253_079_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				356.00	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	25						25			25			25		25
H5253	080	0	1	02	01	H5253_080_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	080	0	1	02	01	H5253_080_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	080	0	1	02	01	H5253_080_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	080	0	1	02	01	H5253_080_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	080	0	1	02	01	H5253_080_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				400.00	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	25						25			25			25		25
H5253	081	0	1	02	01	H5253_081_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	081	0	1	02	01	H5253_081_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	081	0	1	02	01	H5253_081_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	081	0	1	02	01	H5253_081_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	081	0	1	02	01	H5253_081_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				418.00	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	25						25			25			25		25
H5253	082	0	1	02	01	H5253_082_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	082	0	1	02	01	H5253_082_0	4			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																														
H5253	082	0	1	02	01	H5253_082_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				48.00	22		22																				22															22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	22		22						22				22		22
H5253	082	0	1	02	01	H5253_082_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				64.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	082	0	1	02	01	H5253_082_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	084	0	1	02	01	H5253_084_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																														
H5253	084	0	1	02	01	H5253_084_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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	084	0	1	02	01	H5253_084_0	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H5253	084	0	1	02	01	H5253_084_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	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	25						25			25			25		25
H5253	084	0	1	02	01	H5253_084_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				393.00	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	25						25			25			25		25
H5253	087	0	1	02	01	H5253_087_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	087	0	1	02	01	H5253_087_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	087	0	1	02	01	H5253_087_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	087	0	1	02	01	H5253_087_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	087	0	1	02	01	H5253_087_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				428.00	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	25						25			25			25		25
H5253	088	0	1	02	01	H5253_088_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	088	0	1	02	01	H5253_088_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	088	0	1	02	01	H5253_088_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	088	0	1	02	01	H5253_088_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	088	0	1	02	01	H5253_088_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				398.00	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	25						25			25			25		25
H5253	089	0	1	02	01	H5253_089_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																														
H5253	089	0	1	02	01	H5253_089_0	7			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	089	0	1	02	01	H5253_089_0	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	089	0	1	02	01	H5253_089_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	089	0	1	02	01	H5253_089_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H5253	097	0	1	02	01	H5253_097_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	097	0	1	02	01	H5253_097_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	097	0	1	02	01	H5253_097_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	097	0	1	02	01	H5253_097_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				95.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	097	0	1	02	01	H5253_097_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				353.00	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	25						25			25			25		25
H5253	099	0	1	02	01	H5253_099_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	099	0	1	02	01	H5253_099_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	099	0	1	02	01	H5253_099_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	099	0	1	02	01	H5253_099_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	099	0	1	02	01	H5253_099_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H5253	100	0	1	02	01	H5253_100_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	100	0	1	02	01	H5253_100_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	100	0	1	02	01	H5253_100_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	100	0	1	02	01	H5253_100_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	100	0	1	02	01	H5253_100_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				345.00	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	25						25			25			25		25
H5253	103	0	1	02	01	H5253_103_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	103	0	1	02	01	H5253_103_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	103	0	1	02	01	H5253_103_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	103	0	1	02	01	H5253_103_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				86.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	103	0	1	02	01	H5253_103_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				384.00	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	25						25			25			25		25
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		0.27						0.26	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	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	104	0	1	02	01	H5253_104_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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				386.00	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	25						25			25			25		25
H5253	105	0	1	02	01	H5253_105_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	105	0	1	02	01	H5253_105_0	4			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						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	105	0	1	02	01	H5253_105_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	105	0	1	02	01	H5253_105_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	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	25						25			25			25		25
H5253	105	0	1	02	01	H5253_105_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				424.00	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	25						25			25			25		25
H5253	108	1	1	02	01	H5253_108_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	1	1	02	01	H5253_108_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	1	1	02	01	H5253_108_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	108	1	1	02	01	H5253_108_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	108	1	1	02	01	H5253_108_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	108	2	1	02	01	H5253_108_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	2	1	02	01	H5253_108_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	2	1	02	01	H5253_108_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	108	2	1	02	01	H5253_108_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	108	2	1	02	01	H5253_108_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	108	3	1	02	01	H5253_108_3	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	3	1	02	01	H5253_108_3	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	108	3	1	02	01	H5253_108_3	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	108	3	1	02	01	H5253_108_3	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				69.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	108	3	1	02	01	H5253_108_3	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				358.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	109	1	1	02	01	H5253_109_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	1	1	02	01	H5253_109_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	1	1	02	01	H5253_109_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	109	1	1	02	01	H5253_109_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	109	1	1	02	01	H5253_109_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H5253	109	2	1	02	01	H5253_109_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	2	1	02	01	H5253_109_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	2	1	02	01	H5253_109_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	109	2	1	02	01	H5253_109_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	109	2	1	02	01	H5253_109_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H5253	109	4	1	02	01	H5253_109_4	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	4	1	02	01	H5253_109_4	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	109	4	1	02	01	H5253_109_4	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	109	4	1	02	01	H5253_109_4	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	109	4	1	02	01	H5253_109_4	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H5253	110	0	1	02	01	H5253_110_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	110	0	1	02	01	H5253_110_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	110	0	1	02	01	H5253_110_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	110	0	1	02	01	H5253_110_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	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	25						25			25			25		25
H5253	110	0	1	02	01	H5253_110_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H5253	111	1	1	02	01	H5253_111_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	111	1	1	02	01	H5253_111_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	111	1	1	02	01	H5253_111_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	111	1	1	02	01	H5253_111_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	111	1	1	02	01	H5253_111_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				401.00	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	25						25			25			25		25
H5253	111	2	1	02	01	H5253_111_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	111	2	1	02	01	H5253_111_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	111	2	1	02	01	H5253_111_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	111	2	1	02	01	H5253_111_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	111	2	1	02	01	H5253_111_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				401.00	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	25						25			25			25		25
H5253	112	1	1	02	01	H5253_112_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																														
H5253	112	1	1	02	01	H5253_112_1	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						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	112	1	1	02	01	H5253_112_1	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	112	1	1	02	01	H5253_112_1	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	112	1	1	02	01	H5253_112_1	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				415.00	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	25						25			25			25		25
H5253	112	2	1	02	01	H5253_112_2	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																														
H5253	112	2	1	02	01	H5253_112_2	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						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	112	2	1	02	01	H5253_112_2	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	112	2	1	02	01	H5253_112_2	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	112	2	1	02	01	H5253_112_2	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				415.00	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	25						25			25			25		25
H5253	116	0	1	02	01	H5253_116_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5253	116	0	1	02	01	H5253_116_0	4		N	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																														
H5253	116	0	1	02	01	H5253_116_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H5253	116	0	1	02	01	H5253_116_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	116	0	1	02	01	H5253_116_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				359.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	117	0	1	02	01	H5253_117_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	117	0	1	02	01	H5253_117_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	117	0	1	02	01	H5253_117_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	117	0	1	02	01	H5253_117_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	117	0	1	02	01	H5253_117_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				414.00	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	25						25			25			25		25
H5253	119	0	1	02	01	H5253_119_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	119	0	1	02	01	H5253_119_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	119	0	1	02	01	H5253_119_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	119	0	1	02	01	H5253_119_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	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	25						25			25			25		25
H5253	119	0	1	02	01	H5253_119_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				336.00	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	25						25			25			25		25
H5253	120	0	1	02	01	H5253_120_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	120	0	1	02	01	H5253_120_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	120	0	1	02	01	H5253_120_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	120	0	1	02	01	H5253_120_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	120	0	1	02	01	H5253_120_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H5253	121	0	1	02	01	H5253_121_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	121	0	1	02	01	H5253_121_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	121	0	1	02	01	H5253_121_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				33.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	121	0	1	02	01	H5253_121_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				50.00	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	25						25			25			25		25
H5253	121	0	1	02	01	H5253_121_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H5253	122	0	1	01	01	H5253_122_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H5253	122	0	1	01	01	H5253_122_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	122	0	1	01	01	H5253_122_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				59.00	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	25		25						25				25		25
H5253	122	0	1	01	01	H5253_122_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	122	0	1	01	01	H5253_122_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				387.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	124	1	1	02	01	H5253_124_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	124	1	1	02	01	H5253_124_1	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	124	1	1	02	01	H5253_124_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				49.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H5253	124	1	1	02	01	H5253_124_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	124	1	1	02	01	H5253_124_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				423.00	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	25						25			25			25		25
H5253	124	2	1	02	01	H5253_124_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	124	2	1	02	01	H5253_124_2	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	124	2	1	02	01	H5253_124_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				49.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H5253	124	2	1	02	01	H5253_124_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	124	2	1	02	01	H5253_124_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				423.00	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	25						25			25			25		25
H5253	125	1	1	02	01	H5253_125_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	125	1	1	02	01	H5253_125_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	125	1	1	02	01	H5253_125_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	125	1	1	02	01	H5253_125_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	125	1	1	02	01	H5253_125_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H5253	125	2	1	02	01	H5253_125_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	125	2	1	02	01	H5253_125_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	125	2	1	02	01	H5253_125_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	125	2	1	02	01	H5253_125_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				82.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	125	2	1	02	01	H5253_125_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H5253	126	1	1	02	01	H5253_126_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	126	1	1	02	01	H5253_126_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	126	1	1	02	01	H5253_126_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	126	1	1	02	01	H5253_126_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	126	1	1	02	01	H5253_126_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H5253	126	2	1	02	01	H5253_126_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	126	2	1	02	01	H5253_126_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	126	2	1	02	01	H5253_126_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	126	2	1	02	01	H5253_126_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	126	2	1	02	01	H5253_126_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H5253	127	0	1	02	01	H5253_127_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	127	0	1	02	01	H5253_127_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	127	0	1	02	01	H5253_127_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	127	0	1	02	01	H5253_127_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				53.00	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	25						25			25			25		25
H5253	127	0	1	02	01	H5253_127_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				376.00	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	25						25			25			25		25
H5253	128	0	1	02	01	H5253_128_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	128	0	1	02	01	H5253_128_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	128	0	1	02	01	H5253_128_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	128	0	1	02	01	H5253_128_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	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	25						25			25			25		25
H5253	128	0	1	02	01	H5253_128_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				323.00	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	25						25			25			25		25
H5253	130	0	1	02	01	H5253_130_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	130	0	1	02	01	H5253_130_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	130	0	1	02	01	H5253_130_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	130	0	1	02	01	H5253_130_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	130	0	1	02	01	H5253_130_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H5253	131	0	1	02	01	H5253_131_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	131	0	1	02	01	H5253_131_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	131	0	1	02	01	H5253_131_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	131	0	1	02	01	H5253_131_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	131	0	1	02	01	H5253_131_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				432.00	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	25						25			25			25		25
H5253	132	0	1	02	01	H5253_132_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	132	0	1	02	01	H5253_132_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	132	0	1	02	01	H5253_132_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	132	0	1	02	01	H5253_132_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	132	0	1	02	01	H5253_132_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				346.00	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	25						25			25			25		25
H5253	133	0	1	02	01	H5253_133_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	133	0	1	02	01	H5253_133_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	133	0	1	02	01	H5253_133_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	133	0	1	02	01	H5253_133_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	133	0	1	02	01	H5253_133_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H5253	134	0	1	02	01	H5253_134_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	134	0	1	02	01	H5253_134_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	134	0	1	02	01	H5253_134_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	134	0	1	02	01	H5253_134_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	134	0	1	02	01	H5253_134_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
H5253	135	0	1	02	01	H5253_135_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	135	0	1	02	01	H5253_135_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	135	0	1	02	01	H5253_135_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	135	0	1	02	01	H5253_135_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	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	25						25			25			25		25
H5253	135	0	1	02	01	H5253_135_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				362.00	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	25						25			25			25		25
H5253	141	0	1	02	01	H5253_141_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	141	0	1	02	01	H5253_141_0	7			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	141	0	1	02	01	H5253_141_0	7			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H5253	141	0	1	02	01	H5253_141_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				72.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	141	0	1	02	01	H5253_141_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				418.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	142	0	1	02	01	H5253_142_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	142	0	1	02	01	H5253_142_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	142	0	1	02	01	H5253_142_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	142	0	1	02	01	H5253_142_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				92.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	142	0	1	02	01	H5253_142_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				431.00	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	25						25			25			25		25
H5253	144	1	1	02	01	H5253_144_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	144	1	1	02	01	H5253_144_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	144	1	1	02	01	H5253_144_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	144	1	1	02	01	H5253_144_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	144	1	1	02	01	H5253_144_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				392.00	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	25						25			25			25		25
H5253	144	2	1	02	01	H5253_144_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	144	2	1	02	01	H5253_144_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	144	2	1	02	01	H5253_144_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	144	2	1	02	01	H5253_144_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	144	2	1	02	01	H5253_144_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				392.00	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	25						25			25			25		25
H5253	145	0	1	02	01	H5253_145_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	145	0	1	02	01	H5253_145_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	145	0	1	02	01	H5253_145_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	145	0	1	02	01	H5253_145_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	145	0	1	02	01	H5253_145_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				393.00	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	25						25			25			25		25
H5253	146	0	1	02	01	H5253_146_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	146	0	1	02	01	H5253_146_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	146	0	1	02	01	H5253_146_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	146	0	1	02	01	H5253_146_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	146	0	1	02	01	H5253_146_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H5253	147	0	1	02	01	H5253_147_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	147	0	1	02	01	H5253_147_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	147	0	1	02	01	H5253_147_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	147	0	1	02	01	H5253_147_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	147	0	1	02	01	H5253_147_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				404.00	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	25						25			25			25		25
H5253	148	0	1	02	01	H5253_148_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	148	0	1	02	01	H5253_148_0	4			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																														
H5253	148	0	1	02	01	H5253_148_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				46.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
H5253	148	0	1	02	01	H5253_148_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				88.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	148	0	1	02	01	H5253_148_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				422.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	150	0	1	02	01	H5253_150_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	150	0	1	02	01	H5253_150_0	4			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																														
H5253	150	0	1	02	01	H5253_150_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H5253	150	0	1	02	01	H5253_150_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				88.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	150	0	1	02	01	H5253_150_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				429.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	154	0	1	02	01	H5253_154_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	154	0	1	02	01	H5253_154_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	154	0	1	02	01	H5253_154_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	154	0	1	02	01	H5253_154_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				76.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	154	0	1	02	01	H5253_154_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				454.00	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	25						25			25			25		25
H5253	155	0	1	02	01	H5253_155_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																														
H5253	155	0	1	02	01	H5253_155_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						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	155	0	1	02	01	H5253_155_0	7			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H5253	155	0	1	02	01	H5253_155_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	155	0	1	02	01	H5253_155_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				410.00	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	25						25			25			25		25
H5253	157	1	1	02	01	H5253_157_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	157	1	1	02	01	H5253_157_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	157	1	1	02	01	H5253_157_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	157	1	1	02	01	H5253_157_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	157	1	1	02	01	H5253_157_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H5253	157	2	1	02	01	H5253_157_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	157	2	1	02	01	H5253_157_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	157	2	1	02	01	H5253_157_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	157	2	1	02	01	H5253_157_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	157	2	1	02	01	H5253_157_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H5253	159	0	1	02	01	H5253_159_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	159	0	1	02	01	H5253_159_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	159	0	1	02	01	H5253_159_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	159	0	1	02	01	H5253_159_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	159	0	1	02	01	H5253_159_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H5253	161	0	1	02	01	H5253_161_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	161	0	1	02	01	H5253_161_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	161	0	1	02	01	H5253_161_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				50.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H5253	161	0	1	02	01	H5253_161_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	161	0	1	02	01	H5253_161_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				457.00	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	25						25			25			25		25
H5253	162	1	1	02	01	H5253_162_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	162	1	1	02	01	H5253_162_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	162	1	1	02	01	H5253_162_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	162	1	1	02	01	H5253_162_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	162	1	1	02	01	H5253_162_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H5253	162	2	1	02	01	H5253_162_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	162	2	1	02	01	H5253_162_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	162	2	1	02	01	H5253_162_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	162	2	1	02	01	H5253_162_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	162	2	1	02	01	H5253_162_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H5253	168	0	1	02	01	H5253_168_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	168	0	1	02	01	H5253_168_0	4			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																														
H5253	168	0	1	02	01	H5253_168_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H5253	168	0	1	02	01	H5253_168_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				62.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	168	0	1	02	01	H5253_168_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				395.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	169	0	1	02	01	H5253_169_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	169	0	1	02	01	H5253_169_0	4			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																														
H5253	169	0	1	02	01	H5253_169_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				38.00	16		16																				16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	16		16						16				16		16
H5253	169	0	1	02	01	H5253_169_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				86.00	39																				39																	39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	169	0	1	02	01	H5253_169_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				409.00	27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	171	0	1	02	01	H5253_171_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	171	0	1	02	01	H5253_171_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	171	0	1	02	01	H5253_171_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				50.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	21		21						21			21	21		21
H5253	171	0	1	02	01	H5253_171_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	171	0	1	02	01	H5253_171_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	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	25						25			25			25		25
H5253	172	0	1	02	01	H5253_172_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	172	0	1	02	01	H5253_172_0	4			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																														
H5253	172	0	1	02	01	H5253_172_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	21		21																				21															21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	21		21						21				21		21
H5253	172	0	1	02	01	H5253_172_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				73.00	46																				46																	46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	172	0	1	02	01	H5253_172_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				356.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	173	0	1	02	01	H5253_173_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	173	0	1	02	01	H5253_173_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	173	0	1	02	01	H5253_173_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	173	0	1	02	01	H5253_173_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	173	0	1	02	01	H5253_173_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				364.00	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	25						25			25			25		25
H5253	174	0	1	02	01	H5253_174_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	174	0	1	02	01	H5253_174_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	174	0	1	02	01	H5253_174_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5253	174	0	1	02	01	H5253_174_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	174	0	1	02	01	H5253_174_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H5253	175	0	1	02	01	H5253_175_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	175	0	1	02	01	H5253_175_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	175	0	1	02	01	H5253_175_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				50.00	22		22																										22						22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	22		22						22			22	22		22
H5253	175	0	1	02	01	H5253_175_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	45																										45						45					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	175	0	1	02	01	H5253_175_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				407.00	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	25						25			25			25		25
H5253	176	0	1	02	01	H5253_176_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	176	0	1	02	01	H5253_176_0	4			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																														
H5253	176	0	1	02	01	H5253_176_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				53.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H5253	176	0	1	02	01	H5253_176_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				63.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	176	0	1	02	01	H5253_176_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				392.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	178	0	1	02	01	H5253_178_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	178	0	1	02	01	H5253_178_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	178	0	1	02	01	H5253_178_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	20		20						20			20	20		20
H5253	178	0	1	02	01	H5253_178_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	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	25						25			25			25		25
H5253	178	0	1	02	01	H5253_178_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				411.00	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	25						25			25			25		25
H5253	179	0	1	02	01	H5253_179_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	179	0	1	02	01	H5253_179_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	179	0	1	02	01	H5253_179_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H5253	179	0	1	02	01	H5253_179_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	179	0	1	02	01	H5253_179_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				421.00	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	25						25			25			25		25
H5253	180	0	1	02	01	H5253_180_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	180	0	1	02	01	H5253_180_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	180	0	1	02	01	H5253_180_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				44.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H5253	180	0	1	02	01	H5253_180_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	180	0	1	02	01	H5253_180_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				366.00	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	25						25			25			25		25
H5253	182	0	1	02	01	H5253_182_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	182	0	1	02	01	H5253_182_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	182	0	1	02	01	H5253_182_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H5253	182	0	1	02	01	H5253_182_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	182	0	1	02	01	H5253_182_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H5253	183	0	1	02	01	H5253_183_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	183	0	1	02	01	H5253_183_0	4			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																														
H5253	183	0	1	02	01	H5253_183_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	23		23																				23															23			23								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	23		23						23				23		23
H5253	183	0	1	02	01	H5253_183_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				68.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	183	0	1	02	01	H5253_183_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				425.00	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	184	0	1	02	01	H5253_184_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5253	184	0	1	02	01	H5253_184_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	184	0	1	02	01	H5253_184_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H5253	184	0	1	02	01	H5253_184_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	184	0	1	02	01	H5253_184_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	185	0	1	02	01	H5253_185_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	185	0	1	02	01	H5253_185_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	185	0	1	02	01	H5253_185_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	185	0	1	02	01	H5253_185_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	185	0	1	02	01	H5253_185_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H5253	186	0	1	02	01	H5253_186_0	11			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		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	11			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		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	11			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H5253	186	0	1	02	01	H5253_186_0	11			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	186	0	1	02	01	H5253_186_0	11			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H5253	187	0	1	02	01	H5253_187_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	187	0	1	02	01	H5253_187_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	187	0	1	02	01	H5253_187_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	187	0	1	02	01	H5253_187_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	187	0	1	02	01	H5253_187_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				399.00	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	25						25			25			25		25
H5253	188	0	1	02	01	H5253_188_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	188	0	1	02	01	H5253_188_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	188	0	1	02	01	H5253_188_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H5253	188	0	1	02	01	H5253_188_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	45																										45						45					45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	188	0	1	02	01	H5253_188_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				400.00	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	25						25			25			25		25
H5253	189	0	1	02	01	H5253_189_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	189	0	1	02	01	H5253_189_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	189	0	1	02	01	H5253_189_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				50.00	22		22																										22						22			22			22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	22		22						22			22	22		22
H5253	189	0	1	02	01	H5253_189_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	46																										46						46					46			46								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	189	0	1	02	01	H5253_189_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				395.00	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	25						25			25			25		25
H5253	190	0	1	02	01	H5253_190_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	190	0	1	02	01	H5253_190_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	190	0	1	02	01	H5253_190_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H5253	190	0	1	02	01	H5253_190_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	190	0	1	02	01	H5253_190_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				406.00	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	25						25			25			25		25
H5253	192	0	1	02	01	H5253_192_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	192	0	1	02	01	H5253_192_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	192	0	1	02	01	H5253_192_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				48.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
H5253	192	0	1	02	01	H5253_192_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	192	0	1	02	01	H5253_192_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				419.00	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	25						25			25			25		25
H5253	193	1	1	02	01	H5253_193_1	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	193	1	1	02	01	H5253_193_1	4			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																														
H5253	193	1	1	02	01	H5253_193_1	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				64.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H5253	193	1	1	02	01	H5253_193_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	193	1	1	02	01	H5253_193_1	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				425.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	193	2	1	02	01	H5253_193_2	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	193	2	1	02	01	H5253_193_2	4			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																														
H5253	193	2	1	02	01	H5253_193_2	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				64.00	24		24																				24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	24		24						24				24		24
H5253	193	2	1	02	01	H5253_193_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	42																				42																	42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	193	2	1	02	01	H5253_193_2	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				425.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5253	195	0	1	02	01	H5253_195_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	195	0	1	02	01	H5253_195_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	195	0	1	02	01	H5253_195_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H5253	195	0	1	02	01	H5253_195_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	195	0	1	02	01	H5253_195_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H5253	196	0	1	02	01	H5253_196_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	196	0	1	02	01	H5253_196_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	196	0	1	02	01	H5253_196_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	21		21																										21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	21		21						21			21	21		21
H5253	196	0	1	02	01	H5253_196_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	196	0	1	02	01	H5253_196_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				387.00	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	25						25			25			25		25
H5253	197	0	1	02	01	H5253_197_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	197	0	1	02	01	H5253_197_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	197	0	1	02	01	H5253_197_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	19		19						19			19	19		19
H5253	197	0	1	02	01	H5253_197_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				61.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	197	0	1	02	01	H5253_197_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				398.00	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	25						25			25			25		25
H5253	198	0	1	02	01	H5253_198_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	198	0	1	02	01	H5253_198_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	198	0	1	02	01	H5253_198_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	198	0	1	02	01	H5253_198_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	198	0	1	02	01	H5253_198_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				320.00	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	25						25			25			25		25
H5253	199	0	1	02	01	H5253_199_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	199	0	1	02	01	H5253_199_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	199	0	1	02	01	H5253_199_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5253	199	0	1	02	01	H5253_199_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				94.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	199	0	1	02	01	H5253_199_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				330.00	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	25						25			25			25		25
H5253	201	0	1	02	01	H5253_201_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	201	0	1	02	01	H5253_201_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	201	0	1	02	01	H5253_201_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	201	0	1	02	01	H5253_201_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	201	0	1	02	01	H5253_201_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				391.00	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	25						25			25			25		25
H5253	202	0	1	02	01	H5253_202_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	202	0	1	02	01	H5253_202_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	202	0	1	02	01	H5253_202_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				42.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	18		18						18			18	18		18
H5253	202	0	1	02	01	H5253_202_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	202	0	1	02	01	H5253_202_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				380.00	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	25						25			25			25		25
H5253	203	0	1	02	01	H5253_203_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	203	0	1	02	01	H5253_203_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	203	0	1	02	01	H5253_203_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	203	0	1	02	01	H5253_203_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	203	0	1	02	01	H5253_203_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				343.00	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	25						25			25			25		25
H5253	204	0	1	02	01	H5253_204_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	204	0	1	02	01	H5253_204_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	204	0	1	02	01	H5253_204_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	204	0	1	02	01	H5253_204_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	204	0	1	02	01	H5253_204_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				357.00	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	25						25			25			25		25
H5253	206	0	1	02	01	H5253_206_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	206	0	1	02	01	H5253_206_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	206	0	1	02	01	H5253_206_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	206	0	1	02	01	H5253_206_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	206	0	1	02	01	H5253_206_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				402.00	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	25						25			25			25		25
H5253	207	0	1	02	01	H5253_207_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	207	0	1	02	01	H5253_207_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	207	0	1	02	01	H5253_207_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H5253	207	0	1	02	01	H5253_207_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	207	0	1	02	01	H5253_207_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				382.00	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	25						25			25			25		25
H5253	208	0	1	02	01	H5253_208_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	208	0	1	02	01	H5253_208_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	208	0	1	02	01	H5253_208_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5253	208	0	1	02	01	H5253_208_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	208	0	1	02	01	H5253_208_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H5253	209	0	1	02	01	H5253_209_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	209	0	1	02	01	H5253_209_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5253	209	0	1	02	01	H5253_209_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H5253	209	0	1	02	01	H5253_209_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5253	209	0	1	02	01	H5253_209_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				367.00	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	25						25			25			25		25
H5262	001	0	1	01	01	H5262_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	001	0	1	01	01	H5262_001_0	4			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	25.00																			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																														
H5262	001	0	1	01	01	H5262_001_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.02	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	20	20	20				20	20	20				20		20
H5262	001	0	1	01	01	H5262_001_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				64.22	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		35.00	25	25	25				25	25	25				25		25
H5262	001	0	1	01	01	H5262_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	001	0	1	01	01	H5262_001_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	003	0	1	01	01	H5262_003_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	003	0	1	01	01	H5262_003_0	4			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	25.00																			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																														
H5262	003	0	1	01	01	H5262_003_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				62.48	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	20	20	20				20	20	20				20		20
H5262	003	0	1	01	01	H5262_003_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				66.87	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		35.00	25	25	25				25	25	25				25		25
H5262	003	0	1	01	01	H5262_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	007	0	1	01	01	H5262_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	007	0	1	01	01	H5262_007_0	4			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	25.00																			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																														
H5262	007	0	1	01	01	H5262_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				55.86	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	20	20	20				20	20	20				20		20
H5262	007	0	1	01	01	H5262_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				63.43	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		35.00	25	25	25				25	25	25				25		25
H5262	007	0	1	01	01	H5262_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	007	0	1	01	01	H5262_007_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	008	0	1	01	01	H5262_008_0	4			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	5.00																			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, Select Care Drugs																														
H5262	008	0	1	01	01	H5262_008_0	4			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	25.00																			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																														
H5262	008	0	1	01	01	H5262_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				61.04	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	20	20	20				20	20	20				20		20
H5262	008	0	1	01	01	H5262_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				67.32	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		35.00	25	25	25				25	25	25				25		25
H5262	008	0	1	01	01	H5262_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	021	0	1	01	01	H5262_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	021	0	1	01	01	H5262_021_0	4			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	25.00																			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																														
H5262	021	0	1	01	01	H5262_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				65.38	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	20	20	20				20	20	20				20		20
H5262	021	0	1	01	01	H5262_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				64.58	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		35.00	25	25	25				25	25	25				25		25
H5262	021	0	1	01	01	H5262_021_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	021	0	1	01	01	H5262_021_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	023	0	1	01	01	H5262_023_0	4			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	5.00																			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, Select Care Drugs																														
H5262	023	0	1	01	01	H5262_023_0	4			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	25.00																			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																														
H5262	023	0	1	01	01	H5262_023_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				63.02	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	20	20	20				20	20	20				20		20
H5262	023	0	1	01	01	H5262_023_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				67.18	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		35.00	25	25	25				25	25	25				25		25
H5262	023	0	1	01	01	H5262_023_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					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	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	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				2.05	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				7.02	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				55.57	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				55.53	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	25	25	25				25	25	25				25		25
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				2.11	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				7.25	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				57.93	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				59.45	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	25	25	25				25	25	25				25		25
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	032	0	1	01	01	H5262_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	032	0	1	01	01	H5262_032_0	4			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	25.00																			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																														
H5262	032	0	1	01	01	H5262_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				63.83	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		35.00	20	20	20				20	20	20				20		20
H5262	032	0	1	01	01	H5262_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				68.42	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		35.00	25	25	25				25	25	25				25		25
H5262	032	0	1	01	01	H5262_032_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	032	0	1	01	01	H5262_032_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	033	0	1	01	01	H5262_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H5262	033	0	1	01	01	H5262_033_0	4			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	25.00																			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																														
H5262	033	0	1	01	01	H5262_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				64.19	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	20	20	20				20	20	20				20		20
H5262	033	0	1	01	01	H5262_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				67.32	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		35.00	25	25	25				25	25	25				25		25
H5262	033	0	1	01	01	H5262_033_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5262	033	0	1	01	01	H5262_033_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5272	001	0	1	01	01	H5272_001_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5272	001	0	1	01	01	H5272_001_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5272	001	0	1	01	01	H5272_001_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											88.07	20	20	20				88.07	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5272	001	0	1	01	01	H5272_001_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5272	001	0	1	01	01	H5272_001_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5272	001	0	1	01	01	H5272_001_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H5273	001	0	1	01	01	H5273_001_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					2.00	4.00	6.00					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H5273	001	0	1	01	01	H5273_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											47.42	20	20	20				47.12	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H5273	001	0	1	01	01	H5273_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											46.93	25	25	25				52.64	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	25	25	25	25	25	25	25	25	25				25		25
H5273	001	0	1	01	01	H5273_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												26							26						26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H5273	001	0	1	01	01	H5273_001_0	7			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																														
H5294	010	0	1	01	01	H5294_010_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	010	0	1	01	01	H5294_010_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	010	0	1	01	01	H5294_010_0	8		N	Preferred Brand	3	11	1	2	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					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	105.00		70.00	105.00		70.00	94.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	010	0	1	01	01	H5294_010_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											48.04	42	42	42				48.04	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	010	0	1	01	01	H5294_010_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	010	0	1	01	01	H5294_010_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	011	0	1	01	01	H5294_011_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5294	011	0	1	01	01	H5294_011_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5294	011	0	1	01	01	H5294_011_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											147.84	25	25	25				147.84	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	011	0	1	01	01	H5294_011_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.18	35	35	35				99.18	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	011	0	1	01	01	H5294_011_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	011	0	1	01	01	H5294_011_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	013	0	1	01	01	H5294_013_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											88.81	20	20	20				88.81	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5294	013	0	1	01	01	H5294_013_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											54.12	37	37	37				54.12	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	013	0	1	01	01	H5294_013_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	015	0	1	01	01	H5294_015_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	015	0	1	01	01	H5294_015_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	015	0	1	01	01	H5294_015_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											88.29	20	20	20				88.29	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5294	015	0	1	01	01	H5294_015_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											54.53	39	39	39				54.53	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	015	0	1	01	01	H5294_015_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	015	0	1	01	01	H5294_015_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00												6.00	9.00					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																														
H5294	016	0	1	01	01	H5294_016_0	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	016	0	1	01	01	H5294_016_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											89.37	20	20	20				89.37	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5294	016	0	1	01	01	H5294_016_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											44.25	38	38	38				44.25	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	016	0	1	01	01	H5294_016_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	017	0	1	01	01	H5294_017_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5294	017	0	1	01	01	H5294_017_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5294	017	0	1	01	01	H5294_017_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.96	25	25	25				129.96	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	017	0	1	01	01	H5294_017_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.04	35	35	35				68.04	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	017	0	1	01	01	H5294_017_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	017	0	1	01	01	H5294_017_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5294	018	0	1	01	01	H5294_018_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5294	018	0	1	01	01	H5294_018_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											137.08	25	25	25				137.08	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	018	0	1	01	01	H5294_018_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.57	36	36	36				67.57	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	018	0	1	01	01	H5294_018_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	018	0	1	01	01	H5294_018_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5294	019	0	1	01	01	H5294_019_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5294	019	0	1	01	01	H5294_019_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.36	25	25	25				130.36	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	019	0	1	01	01	H5294_019_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											75.60	42	42	42				75.60	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	019	0	1	01	01	H5294_019_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	019	0	1	01	01	H5294_019_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	021	0	1	01	01	H5294_021_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	021	0	1	01	01	H5294_021_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	021	0	1	01	01	H5294_021_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.51	20	20	20				79.51	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5294	021	0	1	01	01	H5294_021_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	021	0	1	01	01	H5294_021_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	021	0	1	01	01	H5294_021_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	022	0	1	01	01	H5294_022_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	022	0	1	01	01	H5294_022_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	022	0	1	01	01	H5294_022_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.46	25	25	25				97.46	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	022	0	1	01	01	H5294_022_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	022	0	1	01	01	H5294_022_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	022	0	1	01	01	H5294_022_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	023	0	1	01	01	H5294_023_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	023	0	1	01	01	H5294_023_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	023	0	1	01	01	H5294_023_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.70	25	25	25				100.70	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	023	0	1	01	01	H5294_023_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	023	0	1	01	01	H5294_023_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	023	0	1	01	01	H5294_023_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	024	0	1	01	01	H5294_024_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	024	0	1	01	01	H5294_024_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	024	0	1	01	01	H5294_024_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.27	25	25	25				99.27	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	024	0	1	01	01	H5294_024_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	024	0	1	01	01	H5294_024_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	024	0	1	01	01	H5294_024_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	025	0	1	01	01	H5294_025_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	025	0	1	01	01	H5294_025_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	025	0	1	01	01	H5294_025_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											101.89	25	25	25				101.89	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	025	0	1	01	01	H5294_025_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5294	025	0	1	01	01	H5294_025_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5294	025	0	1	01	01	H5294_025_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	01	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	25	25	25				25	25	25				25		25
H5296	003	0	1	01	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	25	25	25				25	25	25				25		25
H5296	003	0	1	01	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	25	25	25				25	25	25				25		25
H5296	003	0	1	01	01	H5296_003_0	9			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.53	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		35.00	25	25	25				25	25	25				25		25
H5296	003	0	1	01	01	H5296_003_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				603.30	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	003	0	1	01	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	004	0	1	02	01	H5296_004_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	004	0	1	02	01	H5296_004_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				6.34	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5296	004	0	1	02	01	H5296_004_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				70.72	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	35.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5296	004	0	1	02	01	H5296_004_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				35.82	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		35.00	25	25	25				25	25	25				25		25
H5296	004	0	1	02	01	H5296_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				473.28	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	004	0	1	02	01	H5296_004_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	006	0	1	01	01	H5296_006_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	006	0	1	01	01	H5296_006_0	10			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	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	25	25	25				25	25	25				25		25
H5296	006	0	1	01	01	H5296_006_0	10			Preferred Brand	4	11	3	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	45.00	90.00	135.00																			45.00	90.00	135.00																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5296	006	0	1	01	01	H5296_006_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				91.84	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		35.00	25	25	25				25	25	25				25		25
H5296	006	0	1	01	01	H5296_006_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				516.75	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	006	0	1	01	01	H5296_006_0	10			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	0.00																			5.00	10.00	0.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	007	0	1	01	01	H5296_007_0	9			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	007	0	1	01	01	H5296_007_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	25	25	25				25	25	25				25		25
H5296	007	0	1	01	01	H5296_007_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	25	25	25				25	25	25				25		25
H5296	007	0	1	01	01	H5296_007_0	9			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				44.04	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		35.00	25	25	25				25	25	25				25		25
H5296	007	0	1	01	01	H5296_007_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				689.10	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	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	008	0	1	01	01	H5296_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	008	0	1	01	01	H5296_008_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	25	25	25				25	25	25				25		25
H5296	008	0	1	01	01	H5296_008_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	25	25	25				25	25	25				25		25
H5296	008	0	1	01	01	H5296_008_0	8			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				84.68	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		35.00	25	25	25				25	25	25				25		25
H5296	008	0	1	01	01	H5296_008_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				725.09	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	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	009	0	1	02	01	H5296_009_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	25	25	25				25	25	25				25		25
H5296	009	0	1	02	01	H5296_009_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.21	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5296	009	0	1	02	01	H5296_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				75.16	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	25	25	25				25	25	25				25		25
H5296	009	0	1	02	01	H5296_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				46.72	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		35.00	25	25	25				25	25	25				25		25
H5296	009	0	1	02	01	H5296_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				513.41	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	009	0	1	02	01	H5296_009_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	010	0	1	01	01	H5296_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	010	0	1	01	01	H5296_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	010	0	1	01	01	H5296_010_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	25	25	25				25	25	25				25		25
H5296	010	0	1	01	01	H5296_010_0	8			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				95.24	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		35.00	25	25	25				25	25	25				25		25
H5296	010	0	1	01	01	H5296_010_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				699.52	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	010	0	1	01	01	H5296_010_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	011	0	1	01	01	H5296_011_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	25	25	25				25	25	25				25		25
H5296	011	0	1	01	01	H5296_011_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5296	011	0	1	01	01	H5296_011_0	6			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	25	25	25				25	25	25				25		25
H5296	011	0	1	01	01	H5296_011_0	6			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.19	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		35.00	25	25	25				25	25	25				25		25
H5296	011	0	1	01	01	H5296_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				473.40	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5296	011	0	1	01	01	H5296_011_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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	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	0	0	0				0	0	0				0		0
H5299	001	0	1	01	01	H5299_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																			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	25	25	25				25	25	25				25		25
H5299	001	0	1	01	01	H5299_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				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	25	25	25				25	25	25				25		25
H5299	001	0	1	01	01	H5299_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				56.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	001	0	1	01	01	H5299_001_0	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	25						25						25		25
H5299	002	0	1	01	01	H5299_002_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	0	0	0				0	0	0				0		0
H5299	002	0	1	01	01	H5299_002_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	25	25	25				25	25	25				25		25
H5299	002	0	1	01	01	H5299_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				60.00	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	22	22	22				22	22	22				22		22
H5299	002	0	1	01	01	H5299_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				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	25	25	25				25	25	25				25		25
H5299	002	0	1	01	01	H5299_002_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	25						25						25		25
H5299	006	0	1	01	01	H5299_006_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H5299	006	0	1	01	01	H5299_006_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	006	0	1	01	01	H5299_006_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				66.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	006	0	1	01	01	H5299_006_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				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	006	0	1	01	01	H5299_006_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	006	0	1	01	01	H5299_006_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	009	0	1	01	01	H5299_009_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H5299	009	0	1	01	01	H5299_009_0	7		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	009	0	1	01	01	H5299_009_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				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	009	0	1	01	01	H5299_009_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				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	009	0	1	01	01	H5299_009_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	009	0	1	01	01	H5299_009_0	7		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	012	0	1	01	01	H5299_012_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	0	0	0				0	0	0				0		0
H5299	012	0	1	01	01	H5299_012_0	6			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	25	25	25				25	25	25				25		25
H5299	012	0	1	01	01	H5299_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				56.00	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	22	22	22				22	22	22				22		22
H5299	012	0	1	01	01	H5299_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				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	25	25	25				25	25	25				25		25
H5299	012	0	1	01	01	H5299_012_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	25						25						25		25
H5299	013	0	1	01	01	H5299_013_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H5299	013	0	1	01	01	H5299_013_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	013	0	1	01	01	H5299_013_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				46.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	013	0	1	01	01	H5299_013_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				65.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	013	0	1	01	01	H5299_013_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	013	0	1	01	01	H5299_013_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	014	0	1	01	01	H5299_014_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5299	014	0	1	01	01	H5299_014_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H5299	014	0	1	01	01	H5299_014_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H5299	014	0	1	01	01	H5299_014_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	014	0	1	01	01	H5299_014_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	014	0	1	01	01	H5299_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	015	0	1	01	01	H5299_015_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5299	015	0	1	01	01	H5299_015_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5299	015	0	1	01	01	H5299_015_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	015	0	1	01	01	H5299_015_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H5299	015	0	1	01	01	H5299_015_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	015	0	1	01	01	H5299_015_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	016	0	1	01	01	H5299_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5299	016	0	1	01	01	H5299_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H5299	016	0	1	01	01	H5299_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H5299	016	0	1	01	01	H5299_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	016	0	1	01	01	H5299_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	016	0	1	01	01	H5299_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	017	0	1	01	01	H5299_017_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5299	017	0	1	01	01	H5299_017_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H5299	017	0	1	01	01	H5299_017_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H5299	017	0	1	01	01	H5299_017_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	017	0	1	01	01	H5299_017_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	017	0	1	01	01	H5299_017_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5299	018	0	1	01	01	H5299_018_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5299	018	0	1	01	01	H5299_018_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H5299	018	0	1	01	01	H5299_018_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H5299	018	0	1	01	01	H5299_018_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5299	018	0	1	01	01	H5299_018_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5299	018	0	1	01	01	H5299_018_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5302	012	0	1	01	01	H5302_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	012	0	1	01	01	H5302_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	012	0	1	01	01	H5302_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				73.96	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	22	22	22				22	22	22				22		22
H5302	012	0	1	01	01	H5302_012_0	2		N	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	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5302	012	0	1	01	01	H5302_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				512.33	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5302	020	0	1	01	01	H5302_020_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	020	0	1	01	01	H5302_020_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	020	0	1	01	01	H5302_020_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.50	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	22	22	22				22	22	22				22		22
H5302	020	0	1	01	01	H5302_020_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				37.39	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5302	020	0	1	01	01	H5302_020_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				511.40	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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											71.54	24	24	24				99.39	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.93	25	25	25				51.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											603.45	25						731.00	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	25			25			25			25			25		25
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											62.92	24	24	24				89.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.17	25	25	25				46.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											520.86	25						636.08	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	25			25			25			25			25		25
H5302	024	0	1	01	01	H5302_024_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	024	0	1	01	01	H5302_024_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5302	024	0	1	01	01	H5302_024_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				73.54	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	22	22	22				22	22	22				22		22
H5302	024	0	1	01	01	H5302_024_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.93	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5302	024	0	1	01	01	H5302_024_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				496.20	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5302	026	0	1	01	01	H5302_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																														
H5302	026	0	1	01	01	H5302_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																														
H5302	026	0	1	01	01	H5302_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											71.85	22	22	22				93.72	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5302	026	0	1	01	01	H5302_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											40.08	25	25	25				49.41	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5302	026	0	1	01	01	H5302_026_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											536.24	25						797.20	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	25			25			25			25			25		25
H5322	025	0	1	02	01	H5322_025_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	025	0	1	02	01	H5322_025_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	025	0	1	02	01	H5322_025_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H5322	025	0	1	02	01	H5322_025_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	025	0	1	02	01	H5322_025_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	026	0	1	02	01	H5322_026_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	026	0	1	02	01	H5322_026_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	026	0	1	02	01	H5322_026_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H5322	026	0	1	02	01	H5322_026_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				53.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	026	0	1	02	01	H5322_026_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				370.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	028	0	1	02	01	H5322_028_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H5322	028	0	1	02	01	H5322_028_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	028	0	1	02	01	H5322_028_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H5322	028	0	1	02	01	H5322_028_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	028	0	1	02	01	H5322_028_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				357.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	029	0	1	02	01	H5322_029_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	029	0	1	02	01	H5322_029_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	029	0	1	02	01	H5322_029_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				49.00	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	25		25						25				25		25
H5322	029	0	1	02	01	H5322_029_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	029	0	1	02	01	H5322_029_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				348.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	031	0	1	02	01	H5322_031_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	031	0	1	02	01	H5322_031_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	031	0	1	02	01	H5322_031_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H5322	031	0	1	02	01	H5322_031_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	031	0	1	02	01	H5322_031_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				368.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	033	0	1	02	01	H5322_033_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	033	0	1	02	01	H5322_033_0	4		N	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																														
H5322	033	0	1	02	01	H5322_033_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				62.00	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	25		25						25				25		25
H5322	033	0	1	02	01	H5322_033_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				46.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	033	0	1	02	01	H5322_033_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	034	0	1	02	01	H5322_034_0	4		N	Preferred Generic	4	01	3	2	1	1	110		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																														
H5322	034	0	1	02	01	H5322_034_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	034	0	1	02	01	H5322_034_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H5322	034	0	1	02	01	H5322_034_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				44.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	034	0	1	02	01	H5322_034_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				368.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	038	0	1	02	01	H5322_038_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	038	0	1	02	01	H5322_038_0	4		N	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																														
H5322	038	0	1	02	01	H5322_038_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				61.00	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	25		25						25				25		25
H5322	038	0	1	02	01	H5322_038_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	038	0	1	02	01	H5322_038_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				394.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	040	0	1	02	01	H5322_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	040	0	1	02	01	H5322_040_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	040	0	1	02	01	H5322_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5322	040	0	1	02	01	H5322_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5322	040	0	1	02	01	H5322_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				396.00	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	25						25			25			25		25
H5322	044	0	1	02	01	H5322_044_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	044	0	1	02	01	H5322_044_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	044	0	1	02	01	H5322_044_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5322	044	0	1	02	01	H5322_044_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5322	044	0	1	02	01	H5322_044_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				386.00	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	25						25			25			25		25
H5322	046	0	1	02	01	H5322_046_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	046	0	1	02	01	H5322_046_0	4		N	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																														
H5322	046	0	1	02	01	H5322_046_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H5322	046	0	1	02	01	H5322_046_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				45.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	046	0	1	02	01	H5322_046_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				376.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	047	1	1	02	01	H5322_047_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	047	1	1	02	01	H5322_047_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	047	1	1	02	01	H5322_047_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5322	047	1	1	02	01	H5322_047_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5322	047	1	1	02	01	H5322_047_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H5322	047	2	1	02	01	H5322_047_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	047	2	1	02	01	H5322_047_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5322	047	2	1	02	01	H5322_047_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5322	047	2	1	02	01	H5322_047_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5322	047	2	1	02	01	H5322_047_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				375.00	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	25						25			25			25		25
H5322	049	1	1	02	01	H5322_049_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	049	1	1	02	01	H5322_049_1	4		N	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																														
H5322	049	1	1	02	01	H5322_049_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H5322	049	1	1	02	01	H5322_049_1	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5322	049	1	1	02	01	H5322_049_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	049	2	1	02	01	H5322_049_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	049	2	1	02	01	H5322_049_2	4		N	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																														
H5322	049	2	1	02	01	H5322_049_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H5322	049	2	1	02	01	H5322_049_2	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5322	049	2	1	02	01	H5322_049_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	050	1	1	02	01	H5322_050_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	050	1	1	02	01	H5322_050_1	4		N	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																														
H5322	050	1	1	02	01	H5322_050_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H5322	050	1	1	02	01	H5322_050_1	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5322	050	1	1	02	01	H5322_050_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5322	050	2	1	02	01	H5322_050_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H5322	050	2	1	02	01	H5322_050_2	4		N	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																														
H5322	050	2	1	02	01	H5322_050_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H5322	050	2	1	02	01	H5322_050_2	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5322	050	2	1	02	01	H5322_050_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				380.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	003	0	1	01	01	H5325_003_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	003	0	1	01	01	H5325_003_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	003	0	1	01	01	H5325_003_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				66.69	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	22	22	22				22	22	22				22		22
H5325	003	0	1	01	01	H5325_003_0	2		N	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																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	003	0	1	01	01	H5325_003_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				475.08	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	004	0	1	01	01	H5325_004_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	004	0	1	01	01	H5325_004_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	004	0	1	01	01	H5325_004_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				66.68	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	22	22	22				22	22	22				22		22
H5325	004	0	1	01	01	H5325_004_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				34.44	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	004	0	1	01	01	H5325_004_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				451.06	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	005	0	1	01	01	H5325_005_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	005	0	1	01	01	H5325_005_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	005	0	1	01	01	H5325_005_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.51	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	22	22	22				22	22	22				22		22
H5325	005	0	1	01	01	H5325_005_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.61	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	005	0	1	01	01	H5325_005_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				489.46	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	006	0	1	01	01	H5325_006_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	006	0	1	01	01	H5325_006_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	006	0	1	01	01	H5325_006_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				65.90	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	22	22	22				22	22	22				22		22
H5325	006	0	1	01	01	H5325_006_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				31.55	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	006	0	1	01	01	H5325_006_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				439.45	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	007	0	1	01	01	H5325_007_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	007	0	1	01	01	H5325_007_0	3		N	Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	007	0	1	01	01	H5325_007_0	3		N	Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				63.40	22	22	22																																				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	22	22	22										22		22
H5325	007	0	1	01	01	H5325_007_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				34.21	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H5325	007	0	1	01	01	H5325_007_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				459.29	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H5325	011	0	1	01	01	H5325_011_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	011	0	1	01	01	H5325_011_0	2		N	Generic	4	01	1	2	2	1	111		10			1	30	60	100				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	011	0	1	01	01	H5325_011_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10			1	30	60	100				1	2								10	31				62.98	22	22	22																																				22		22								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	22	22	22										22		22
H5325	011	0	1	01	01	H5325_011_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10			1	30	60	100				1	2								10	31				33.60	25	25	25																																				25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
H5325	011	0	1	01	01	H5325_011_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10			1	30															10	31				440.32	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H5325	012	0	1	01	01	H5325_012_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	012	0	1	01	01	H5325_012_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	012	0	1	01	01	H5325_012_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.16	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	22	22	22				22	22	22				22		22
H5325	012	0	1	01	01	H5325_012_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.93	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	012	0	1	01	01	H5325_012_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				479.22	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	013	0	1	01	01	H5325_013_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	013	0	1	01	01	H5325_013_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	013	0	1	01	01	H5325_013_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.16	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	22	22	22				22	22	22				22		22
H5325	013	0	1	01	01	H5325_013_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.93	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	013	0	1	01	01	H5325_013_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				479.22	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	014	0	1	01	01	H5325_014_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	014	0	1	01	01	H5325_014_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	014	0	1	01	01	H5325_014_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.55	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	22	22	22				22	22	22				22		22
H5325	014	0	1	01	01	H5325_014_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.82	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	014	0	1	01	01	H5325_014_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				480.50	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5325	015	0	1	01	01	H5325_015_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	015	0	1	01	01	H5325_015_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5325	015	0	1	01	01	H5325_015_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.55	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	22	22	22				22	22	22				22		22
H5325	015	0	1	01	01	H5325_015_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.82	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5325	015	0	1	01	01	H5325_015_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				480.50	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5361	001	0	1	04	01	H5361_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	18.00					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	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	40.00					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	9			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											55.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	001	0	1	04	01	H5361_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											54.00	37	37	37				42.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	001	0	1	04	01	H5361_001_0	9			Specialty Tier	4	11	1	1	5	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31												33	33	33					33	33	33				33	33	33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	002	0	1	04	01	H5361_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								7.00	14.00	14.00					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	7			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	16.00					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	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											49.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	002	0	1	04	01	H5361_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											63.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	002	0	1	04	01	H5361_002_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	25	25	25	25	25	25	25	25	25				25		25
H5361	004	0	1	04	01	H5361_004_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								9.00	18.00	18.00					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	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	40.00					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	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											62.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	004	0	1	04	01	H5361_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											61.00	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5361	004	0	1	04	01	H5361_004_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	25	25	25	25	25	25	25	25	25				25		25
H5377	002	0	1	02	01	H5377_002_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	0		0				25		25	0		0	0		0
H5377	002	0	1	02	01	H5377_002_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5377	002	0	1	02	01	H5377_002_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	25		25				25		25	25		25	25		25
H5377	002	0	1	02	01	H5377_002_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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	25		25				25		25	25		25	25		25
H5377	002	0	1	02	01	H5377_002_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	25						25			25			25		25
H5377	003	0	1	01	01	H5377_003_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	0		0				25		25	0		0	0		0
H5377	003	0	1	01	01	H5377_003_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	0		0				25		25	0		0	0		0
H5377	003	0	1	01	01	H5377_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5377	003	0	1	01	01	H5377_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5377	003	0	1	01	01	H5377_003_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	25						25			25			25		25
H5386	003	0	1	01	01	H5386_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	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	7			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	7			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	25	25	25				25	25	25				25		25
H5386	003	0	1	01	01	H5386_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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	25	25	25				25	25	25				25		25
H5386	003	0	1	01	01	H5386_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				568.38	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	25						25						25		25
H5386	003	0	1	01	01	H5386_003_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5386	004	0	1	01	01	H5386_004_0	8			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	8			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	8.00	16.00	24.00																			0.00	0.00	0.00																8.00				8.00		0.27			0.00			0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5386	004	0	1	01	01	H5386_004_0	8			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	25	25	25				25	25	25				25		25
H5386	004	0	1	01	01	H5386_004_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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	25	25	25				25	25	25				25		25
H5386	004	0	1	01	01	H5386_004_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				624.83	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	25						25						25		25
H5386	004	0	1	01	01	H5386_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5386	005	0	1	01	01	H5386_005_0	8			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	8			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	8			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	25	25	25				25	25	25				25		25
H5386	005	0	1	01	01	H5386_005_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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	25	25	25				25	25	25				25		25
H5386	005	0	1	01	01	H5386_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				665.99	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	25						25						25		25
H5386	005	0	1	01	01	H5386_005_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5386	006	0	1	01	01	H5386_006_0	8			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	006	0	1	01	01	H5386_006_0	8			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	006	0	1	01	01	H5386_006_0	8			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	25	25	25				25	25	25				25		25
H5386	006	0	1	01	01	H5386_006_0	8			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	25	25	25				25	25	25				25		25
H5386	006	0	1	01	01	H5386_006_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				665.99	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	25						25						25		25
H5386	006	0	1	01	01	H5386_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5397	001	0	1	01	01	H5397_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	0	0	0				0	0	0				0		0
H5397	001	0	1	01	01	H5397_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	25	25	25				25	25	25				25		25
H5397	001	0	1	01	01	H5397_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				44.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H5397	001	0	1	01	01	H5397_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5397	001	0	1	01	01	H5397_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	25						25						25		25
H5397	002	0	1	01	01	H5397_002_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	0	0	0				0	0	0				0		0
H5397	002	0	1	01	01	H5397_002_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	25	25	25				25	25	25				25		25
H5397	002	0	1	01	01	H5397_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				39.00	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	21	21	21				21	21	21				21		21
H5397	002	0	1	01	01	H5397_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				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	25	25	25				25	25	25				25		25
H5397	002	0	1	01	01	H5397_002_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	25						25						25		25
H5397	003	0	1	01	01	H5397_003_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5397	003	0	1	01	01	H5397_003_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5397	003	0	1	01	01	H5397_003_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5397	003	0	1	01	01	H5397_003_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H5397	003	0	1	01	01	H5397_003_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5397	003	0	1	01	01	H5397_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5397	004	0	1	01	01	H5397_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	0	0	0				0	0	0				0		0
H5397	004	0	1	01	01	H5397_004_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5397	004	0	1	01	01	H5397_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				37.00	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	22	22	22				22	22	22				22		22
H5397	004	0	1	01	01	H5397_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				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	25	25	25				25	25	25				25		25
H5397	004	0	1	01	01	H5397_004_0	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	25						25						25		25
H5397	005	0	1	01	01	H5397_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H5397	005	0	1	01	01	H5397_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5397	005	0	1	01	01	H5397_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				37.00	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	22	22	22				22	22	22				22		22
H5397	005	0	1	01	01	H5397_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				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	25	25	25				25	25	25				25		25
H5397	005	0	1	01	01	H5397_005_0	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	25						25						25		25
H5410	013	0	1	01	01	H5410_013_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	013	0	1	01	01	H5410_013_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	013	0	1	01	01	H5410_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											20.69	24	24	24				23.40	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5410	013	0	1	01	01	H5410_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											52.08	25	25	25				53.87	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	013	0	1	01	01	H5410_013_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											453.88	25						405.12	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	25			25			25			25			25		25
H5410	018	0	1	01	01	H5410_018_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	018	0	1	01	01	H5410_018_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	018	0	1	01	01	H5410_018_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	018	0	1	01	01	H5410_018_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											35.37	50	50	50				33.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	018	0	1	01	01	H5410_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											617.28	33						489.01	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	25			25			25			25			25		25
H5410	024	0	1	01	01	H5410_024_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	024	0	1	01	01	H5410_024_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	024	0	1	01	01	H5410_024_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	024	0	1	01	01	H5410_024_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											70.43	50	50	50				57.66	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	024	0	1	01	01	H5410_024_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											550.12	30						559.13	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	25			25			25			25			25		25
H5410	025	0	1	01	01	H5410_025_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	025	0	1	01	01	H5410_025_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	025	0	1	01	01	H5410_025_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											20.68	23	23	23				20.98	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	025	0	1	01	01	H5410_025_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											48.42	25	25	25				54.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	025	0	1	01	01	H5410_025_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											474.40	25						427.96	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	25			25			25			25			25		25
H5410	026	0	1	01	01	H5410_026_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	026	0	1	01	01	H5410_026_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	026	0	1	01	01	H5410_026_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	026	0	1	01	01	H5410_026_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											60.46	50	50	50				58.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	026	0	1	01	01	H5410_026_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											603.43	29						553.29	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	25			25			25			25			25		25
H5410	031	0	1	01	01	H5410_031_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	031	0	1	01	01	H5410_031_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	031	0	1	01	01	H5410_031_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											18.64	23	23	23				19.48	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	031	0	1	01	01	H5410_031_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											44.66	25	25	25				49.52	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H5410	031	0	1	01	01	H5410_031_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											418.02	25						366.47	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	25			25			25			25			25		25
H5410	032	0	1	01	01	H5410_032_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	032	0	1	01	01	H5410_032_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	032	0	1	01	01	H5410_032_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											21.91	23	23	23				22.72	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	032	0	1	01	01	H5410_032_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											48.06	25	25	25				53.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	032	0	1	01	01	H5410_032_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											487.06	25						412.77	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	25			25			25			25			25		25
H5410	042	0	1	01	01	H5410_042_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	042	0	1	01	01	H5410_042_0	5		N	Generic	4	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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	042	0	1	01	01	H5410_042_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											22.73	23	23	23				23.16	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	042	0	1	01	01	H5410_042_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											49.63	25	25	25				54.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	042	0	1	01	01	H5410_042_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											443.07	25						325.90	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	25			25			25			25			25		25
H5410	045	0	1	01	01	H5410_045_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	045	0	1	01	01	H5410_045_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	045	0	1	01	01	H5410_045_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											20.52	23	23	23				21.65	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	045	0	1	01	01	H5410_045_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											48.00	25	25	25				52.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	045	0	1	01	01	H5410_045_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											469.16	25						405.70	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	25			25			25			25			25		25
H5410	046	0	1	01	01	H5410_046_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	046	0	1	01	01	H5410_046_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	046	0	1	01	01	H5410_046_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											19.73	23	23	23				20.75	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	046	0	1	01	01	H5410_046_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											47.25	25	25	25				51.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	046	0	1	01	01	H5410_046_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											454.02	25						394.04	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	25			25			25			25			25		25
H5410	047	0	1	01	01	H5410_047_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	047	0	1	01	01	H5410_047_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	047	0	1	01	01	H5410_047_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											19.87	23	23	23				20.72	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	047	0	1	01	01	H5410_047_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											45.94	25	25	25				52.10	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	047	0	1	01	01	H5410_047_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											452.00	25						386.99	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	25			25			25			25			25		25
H5410	055	0	1	01	01	H5410_055_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	055	0	1	01	01	H5410_055_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	055	0	1	01	01	H5410_055_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											20.40	23	23	23				21.52	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	055	0	1	01	01	H5410_055_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											47.78	25	25	25				52.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	055	0	1	01	01	H5410_055_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											465.79	25						405.74	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	25			25			25			25			25		25
H5410	056	0	1	01	01	H5410_056_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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	056	0	1	01	01	H5410_056_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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	056	0	1	01	01	H5410_056_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											20.57	23	23	23				21.68	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5410	056	0	1	01	01	H5410_056_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											48.00	25	25	25				52.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	056	0	1	01	01	H5410_056_0	5		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											469.93	25						406.10	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	25			25			25			25			25		25
H5410	059	0	1	01	01	H5410_059_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	059	0	1	01	01	H5410_059_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	059	0	1	01	01	H5410_059_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	059	0	1	01	01	H5410_059_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											76.09	50	50	50				56.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	059	0	1	01	01	H5410_059_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											518.44	25						458.22	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	25			25			25			25			25		25
H5410	060	0	1	01	01	H5410_060_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H5410	060	0	1	01	01	H5410_060_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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H5410	060	0	1	01	01	H5410_060_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	060	0	1	01	01	H5410_060_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											76.09	50	50	50				56.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5410	060	0	1	01	01	H5410_060_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											518.44	25						458.22	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	25			25			25			25			25		25
H5420	001	0	1	01	01	H5420_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5420	001	0	1	01	01	H5420_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5420	001	0	1	01	01	H5420_001_0	4			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						0.81	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			65.00	25.00		25.00	25		25						25			25	25		25
H5420	001	0	1	01	01	H5420_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				87.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5420	001	0	1	01	01	H5420_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				604.00	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	25						25			25			25		25
H5420	003	0	1	01	01	H5420_003_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5420	003	0	1	01	01	H5420_003_0	4			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	003	0	1	01	01	H5420_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				43.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	19		19						19				19		19
H5420	003	0	1	01	01	H5420_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				92.00	41																				41																	41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	003	0	1	01	01	H5420_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				379.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	006	0	1	01	01	H5420_006_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	006	0	1	01	01	H5420_006_0	4		N	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																														
H5420	006	0	1	01	01	H5420_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				50.00	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	25		25						25				25		25
H5420	006	0	1	01	01	H5420_006_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				55.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	006	0	1	01	01	H5420_006_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				381.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	014	0	1	01	01	H5420_014_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5420	014	0	1	01	01	H5420_014_0	4			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	4			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	25		25						25				25		25
H5420	014	0	1	01	01	H5420_014_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				74.00	40																				40																	40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	014	0	1	01	01	H5420_014_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				611.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	015	0	1	01	01	H5420_015_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	015	0	1	01	01	H5420_015_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5420	015	0	1	01	01	H5420_015_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H5420	015	0	1	01	01	H5420_015_0	4		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	35.00						35.00						35.00		35.00	25						25						25		25
H5420	015	0	1	01	01	H5420_015_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				382.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	016	0	1	02	01	H5420_016_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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	016	0	1	02	01	H5420_016_0	4		N	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																														
H5420	016	0	1	02	01	H5420_016_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
H5420	016	0	1	02	01	H5420_016_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				57.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5420	016	0	1	02	01	H5420_016_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				394.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5422	011	0	1	02	01	H5422_011_0	4			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																														
H5422	011	0	1	02	01	H5422_011_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	011	0	1	02	01	H5422_011_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											57.00	25	25	25				84.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H5422	011	0	1	02	01	H5422_011_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.00	30	30	30				14.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5422	011	0	1	02	01	H5422_011_0	4			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																														
H5422	011	0	1	02	01	H5422_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	4			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	4			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	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	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				72.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	013	0	1	02	01	H5422_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				20.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	013	0	1	02	01	H5422_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	013	0	1	02	01	H5422_013_0	4			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	4			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																														
H5422	015	0	1	02	01	H5422_015_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	015	0	1	02	01	H5422_015_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											33.00	20	20	20				37.00	15	15	15				15	15	15															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00	20	20	20	15	15	15	15	15	15				20		20
H5422	015	0	1	02	01	H5422_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		34											32.00	30	30	30				15.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5422	015	0	1	02	01	H5422_015_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	015	0	1	02	01	H5422_015_0	4			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	018	0	1	01	01	H5422_018_0	4		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																														
H5422	018	0	1	01	01	H5422_018_0	4		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				2.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	018	0	1	01	01	H5422_018_0	4		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				78.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	018	0	1	01	01	H5422_018_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				21.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	018	0	1	01	01	H5422_018_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	018	0	1	01	01	H5422_018_0	4		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																														
H5422	019	0	1	01	01	H5422_019_0	5		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																														
H5422	019	0	1	01	01	H5422_019_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				2.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	019	0	1	01	01	H5422_019_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				77.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	019	0	1	01	01	H5422_019_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		34				21.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5422	019	0	1	01	01	H5422_019_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5422	019	0	1	01	01	H5422_019_0	5		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																														
H5425	001	0	1	01	01	H5425_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	001	0	1	01	01	H5425_001_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	001	0	1	01	01	H5425_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											71.78	35	35	35				71.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	001	0	1	01	01	H5425_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	005	0	1	01	01	H5425_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					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	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	005	0	1	01	01	H5425_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											95.73	35	35	35				95.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	005	0	1	01	01	H5425_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	006	0	1	01	01	H5425_006_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	006	0	1	01	01	H5425_006_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	006	0	1	01	01	H5425_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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	006	0	1	01	01	H5425_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											70.13	35	35	35				70.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	006	0	1	01	01	H5425_006_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																														
H5425	007	0	1	01	01	H5425_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	007	0	1	01	01	H5425_007_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	007	0	1	01	01	H5425_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											79.88	35	35	35				79.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	007	0	1	01	01	H5425_007_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	008	0	1	01	01	H5425_008_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	008	0	1	01	01	H5425_008_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	008	0	1	01	01	H5425_008_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	008	0	1	01	01	H5425_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											70.21	35	35	35				70.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	008	0	1	01	01	H5425_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	009	0	1	01	01	H5425_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	009	0	1	01	01	H5425_009_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	009	0	1	01	01	H5425_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											66.63	35	35	35				66.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	009	0	1	01	01	H5425_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	019	0	1	01	01	H5425_019_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	019	0	1	01	01	H5425_019_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	019	0	1	01	01	H5425_019_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	019	0	1	01	01	H5425_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											71.06	35	35	35				71.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	019	0	1	01	01	H5425_019_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	034	0	1	01	01	H5425_034_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	034	0	1	01	01	H5425_034_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	034	0	1	01	01	H5425_034_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	0	000	000	0	0	0	000	000	000	0	0	0	0		0
H5425	034	0	1	01	01	H5425_034_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											55.48	35	35	35				55.48	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	034	0	1	01	01	H5425_034_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	065	0	1	01	01	H5425_065_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	065	0	1	01	01	H5425_065_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	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	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	065	0	1	01	01	H5425_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											72.91	35	35	35				72.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	065	0	1	01	01	H5425_065_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	069	0	1	01	01	H5425_069_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	069	0	1	01	01	H5425_069_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	069	0	1	01	01	H5425_069_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	069	0	1	01	01	H5425_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											75.42	35	35	35				75.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	069	0	1	01	01	H5425_069_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	070	0	1	01	01	H5425_070_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	070	0	1	01	01	H5425_070_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	070	0	1	01	01	H5425_070_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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	070	0	1	01	01	H5425_070_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											59.76	35	35	35				59.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	070	0	1	01	01	H5425_070_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																														
H5425	075	0	1	01	01	H5425_075_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	075	0	1	01	01	H5425_075_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	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	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	075	0	1	01	01	H5425_075_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											65.10	35	35	35				65.10	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	075	0	1	01	01	H5425_075_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	076	0	1	01	01	H5425_076_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	076	0	1	01	01	H5425_076_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	076	0	1	01	01	H5425_076_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	076	0	1	01	01	H5425_076_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											60.33	35	35	35				60.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	076	0	1	01	01	H5425_076_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	082	0	1	01	01	H5425_082_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	082	0	1	01	01	H5425_082_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	082	0	1	01	01	H5425_082_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	082	0	1	01	01	H5425_082_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											79.17	35	35	35				79.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	082	0	1	01	01	H5425_082_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	084	0	1	01	01	H5425_084_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	084	0	1	01	01	H5425_084_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	084	0	1	01	01	H5425_084_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	084	0	1	01	01	H5425_084_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											81.59	35	35	35				81.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	084	0	1	01	01	H5425_084_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	085	0	1	01	01	H5425_085_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	085	0	1	01	01	H5425_085_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	085	0	1	01	01	H5425_085_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	085	0	1	01	01	H5425_085_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											65.67	35	35	35				65.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	085	0	1	01	01	H5425_085_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	086	0	1	01	01	H5425_086_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	086	0	1	01	01	H5425_086_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	086	0	1	01	01	H5425_086_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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	086	0	1	01	01	H5425_086_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											39.19	35	35	35				39.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	086	0	1	01	01	H5425_086_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	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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											34.30	35	35	35				34.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	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																														
H5425	091	0	1	02	01	H5425_091_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	091	0	1	02	01	H5425_091_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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	091	0	1	02	01	H5425_091_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											35.09	35	35	35				35.09	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	091	0	1	02	01	H5425_091_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																														
H5425	092	0	1	01	01	H5425_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								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	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	092	0	1	01	01	H5425_092_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	092	0	1	01	01	H5425_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											69.41	35	35	35				69.41	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	092	0	1	01	01	H5425_092_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																														
H5425	096	0	1	01	01	H5425_096_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	096	0	1	01	01	H5425_096_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	096	0	1	01	01	H5425_096_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	096	0	1	01	01	H5425_096_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											68.43	35	35	35				68.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	096	0	1	01	01	H5425_096_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																														
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											91.93	25	25	25				91.93	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											45.36	30	30	30				45.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	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	098	0	1	01	01	H5425_098_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	098	0	1	01	01	H5425_098_0	9			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											102.23	25	25	25				102.23	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	098	0	1	01	01	H5425_098_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											59.64	30	30	30				59.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	098	0	1	01	01	H5425_098_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	100	0	1	01	01	H5425_100_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	100	0	1	01	01	H5425_100_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	100	0	1	01	01	H5425_100_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	100	0	1	01	01	H5425_100_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											63.82	35	35	35				63.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	100	0	1	01	01	H5425_100_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	101	0	1	01	01	H5425_101_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	101	0	1	01	01	H5425_101_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	101	0	1	01	01	H5425_101_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	101	0	1	01	01	H5425_101_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											66.85	35	35	35				66.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	101	0	1	01	01	H5425_101_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	102	0	1	01	01	H5425_102_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	102	0	1	01	01	H5425_102_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	102	0	1	01	01	H5425_102_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	102	0	1	01	01	H5425_102_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											59.30	35	35	35				59.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	102	0	1	01	01	H5425_102_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											54.99	35	35	35				54.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	105	0	1	01	01	H5425_105_0	8			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	105	0	1	01	01	H5425_105_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								9.00	18.00	18.00					0.00	0.00	0.00											9.00	18.00	18.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	105	0	1	01	01	H5425_105_0	8			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	105	0	1	01	01	H5425_105_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											58.76	35	35	35				58.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	105	0	1	01	01	H5425_105_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
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											60.89	35	35	35				60.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	107	0	1	01	01	H5425_107_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	107	0	1	01	01	H5425_107_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	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	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	107	0	1	01	01	H5425_107_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											71.28	35	35	35				71.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	107	0	1	01	01	H5425_107_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																														
H5425	108	0	1	01	01	H5425_108_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	108	0	1	01	01	H5425_108_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	108	0	1	01	01	H5425_108_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	108	0	1	01	01	H5425_108_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											72.42	35	35	35				72.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	108	0	1	01	01	H5425_108_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											99.59	35	35	35				99.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	110	0	1	01	01	H5425_110_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	110	0	1	01	01	H5425_110_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	110	0	1	01	01	H5425_110_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	110	0	1	01	01	H5425_110_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											84.17	35	35	35				84.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	110	0	1	01	01	H5425_110_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	118	0	1	01	01	H5425_118_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	118	0	1	01	01	H5425_118_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	118	0	1	01	01	H5425_118_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	118	0	1	01	01	H5425_118_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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	118	0	1	01	01	H5425_118_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																														
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	121	0	1	01	01	H5425_121_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	121	0	1	01	01	H5425_121_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	121	0	1	01	01	H5425_121_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	121	0	1	01	01	H5425_121_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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	121	0	1	01	01	H5425_121_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	124	0	1	01	01	H5425_124_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	124	0	1	01	01	H5425_124_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	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	124	0	1	01	01	H5425_124_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	124	0	1	01	01	H5425_124_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											69.89	35	35	35				69.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	124	0	1	01	01	H5425_124_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	125	0	1	01	01	H5425_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	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	125	0	1	01	01	H5425_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	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	125	0	1	01	01	H5425_125_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	125	0	1	01	01	H5425_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											69.89	35	35	35				69.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	125	0	1	01	01	H5425_125_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	126	0	1	01	01	H5425_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	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	126	0	1	01	01	H5425_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	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	126	0	1	01	01	H5425_126_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	126	0	1	01	01	H5425_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											69.89	35	35	35				69.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	126	0	1	01	01	H5425_126_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	127	0	1	01	01	H5425_127_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	127	0	1	01	01	H5425_127_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	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	127	0	1	01	01	H5425_127_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	127	0	1	01	01	H5425_127_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											69.89	35	35	35				69.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	127	0	1	01	01	H5425_127_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	128	0	1	01	01	H5425_128_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	128	0	1	01	01	H5425_128_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	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	128	0	1	01	01	H5425_128_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	128	0	1	01	01	H5425_128_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											69.89	35	35	35				69.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	128	0	1	01	01	H5425_128_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	129	0	1	01	01	H5425_129_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	129	0	1	01	01	H5425_129_0	8			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	20.00					0.00	0.00	0.00											10.00	20.00	20.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	129	0	1	01	01	H5425_129_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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	129	0	1	01	01	H5425_129_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											55.57	35	35	35				55.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	129	0	1	01	01	H5425_129_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																														
H5425	130	0	1	01	01	H5425_130_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	130	0	1	01	01	H5425_130_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	130	0	1	01	01	H5425_130_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	130	0	1	01	01	H5425_130_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											69.90	35	35	35				69.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	130	0	1	01	01	H5425_130_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	131	0	1	01	01	H5425_131_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	131	0	1	01	01	H5425_131_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	131	0	1	01	01	H5425_131_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											75.36	25	25	25				75.36	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	131	0	1	01	01	H5425_131_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											52.53	30	30	30				52.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	131	0	1	01	01	H5425_131_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	132	0	1	02	01	H5425_132_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	132	0	1	02	01	H5425_132_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	132	0	1	02	01	H5425_132_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											75.36	25	25	25				75.36	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H5425	132	0	1	02	01	H5425_132_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											52.53	30	30	30				52.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	132	0	1	02	01	H5425_132_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	133	0	1	01	01	H5425_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				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	133	0	1	01	01	H5425_133_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	133	0	1	01	01	H5425_133_0	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	133	0	1	01	01	H5425_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											81.28	35	35	35				81.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	133	0	1	01	01	H5425_133_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	134	0	1	01	01	H5425_134_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	134	0	1	01	01	H5425_134_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	30.00					0.00	0.00	0.00											15.00	30.00	30.00				0.00	0.00	0.00				15.00				15.00			0.50	0.00		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	134	0	1	01	01	H5425_134_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	126.00				47.00				47.00			1.57	1.40		1.57	1.40	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	134	0	1	01	01	H5425_134_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											69.86	35	35	35				69.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	134	0	1	01	01	H5425_134_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	135	0	1	01	01	H5425_135_0	6			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	10.00					0.00	0.00	0.00											5.00	10.00	10.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	135	0	1	01	01	H5425_135_0	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								12.00	24.00	24.00					0.00	0.00	0.00											12.00	24.00	24.00				0.00	0.00	0.00				12.00				12.00			0.40	0.00		0.40	0.00	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5425	135	0	1	01	01	H5425_135_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	135	0	1	01	01	H5425_135_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											69.88	35	35	35				69.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5425	135	0	1	01	01	H5425_135_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5427	059	0	1	01	01	H5427_059_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	059	0	1	01	01	H5427_059_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	059	0	1	01	01	H5427_059_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	059	0	1	01	01	H5427_059_0	5			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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H5427	060	0	1	01	01	H5427_060_0	6			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	25	25	25	25	25	25	25	25	25				25		25
H5427	060	0	1	01	01	H5427_060_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								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	25	25	25	25	25	25	25	25	25				25		25
H5427	060	0	1	01	01	H5427_060_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																														
H5427	070	0	1	01	01	H5427_070_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	0	0	0	0	0	0	0	0	0				0		0
H5427	070	0	1	01	01	H5427_070_0	6			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, Select Diabetic Drugs																														
H5427	070	0	1	01	01	H5427_070_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								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	25	25	25	25	25	25	25	25	25				25		25
H5427	070	0	1	01	01	H5427_070_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	070	0	1	01	01	H5427_070_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								0.00	0.00	0.00					0.00	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	0	0	0	0	0	0	0	0	0				0		0
H5427	072	0	1	01	01	H5427_072_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	0	0	0	0	0	0	0	0	0				0		0
H5427	072	0	1	01	01	H5427_072_0	6			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	6			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	25	25	25	25	25	25	25	25	25				25		25
H5427	072	0	1	01	01	H5427_072_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	072	0	1	01	01	H5427_072_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	25	25	25	25	25	25	25	25	25				25		25
H5427	077	0	1	01	01	H5427_077_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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H5427	077	0	1	01	01	H5427_077_0	6			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	25	25	25	25	25	25	25	25	25				25		25
H5427	077	0	1	01	01	H5427_077_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								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	25	25	25	25	25	25	25	25	25				25		25
H5427	077	0	1	01	01	H5427_077_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																														
H5427	078	0	1	01	01	H5427_078_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	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5427	078	0	1	01	01	H5427_078_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				78.00	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	25	25	25				25	25	25				25		25
H5427	078	0	1	01	01	H5427_078_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				53.00	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	25	25	25				25	25	25				25		25
H5427	078	0	1	01	01	H5427_078_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																														
H5427	078	0	1	01	01	H5427_078_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																														
H5427	082	0	1	01	01	H5427_082_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	082	0	1	01	01	H5427_082_0	5			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	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	082	0	1	01	01	H5427_082_0	5			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	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	083	0	1	01	01	H5427_083_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	083	0	1	01	01	H5427_083_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	083	0	1	01	01	H5427_083_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	083	0	1	01	01	H5427_083_0	5			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	7		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, 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	0	0				0	0	0				0		0
H5427	087	0	1	01	01	H5427_087_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				79.00	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	25	25	25				25	25	25				25		25
H5427	087	0	1	01	01	H5427_087_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				54.00	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	25	25	25				25	25	25				25		25
H5427	087	0	1	01	01	H5427_087_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																														
H5427	087	0	1	01	01	H5427_087_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																														
H5427	088	0	1	01	01	H5427_088_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	088	0	1	01	01	H5427_088_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	088	0	1	01	01	H5427_088_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	088	0	1	01	01	H5427_088_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	089	0	1	01	01	H5427_089_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	089	0	1	01	01	H5427_089_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	089	0	1	01	01	H5427_089_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	091	0	1	01	01	H5427_091_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	091	0	1	01	01	H5427_091_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	091	0	1	01	01	H5427_091_0	5			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	4			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	093	0	1	01	01	H5427_093_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5427	093	0	1	01	01	H5427_093_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5427	093	0	1	01	01	H5427_093_0	4			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	094	0	1	01	01	H5427_094_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	094	0	1	01	01	H5427_094_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	094	0	1	01	01	H5427_094_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	096	0	1	01	01	H5427_096_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	096	0	1	01	01	H5427_096_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	096	0	1	01	01	H5427_096_0	5			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	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	0	0	0	0	0	0	0	0	0				0		0
H5427	099	0	1	01	01	H5427_099_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	099	0	1	01	01	H5427_099_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								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	25	25	25	25	25	25	25	25	25				25		25
H5427	099	0	1	01	01	H5427_099_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	099	0	1	01	01	H5427_099_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	25	25	25	25	25	25	25	25	25				25		25
H5427	102	0	1	01	01	H5427_102_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	102	0	1	01	01	H5427_102_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	102	0	1	01	01	H5427_102_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	102	0	1	01	01	H5427_102_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	103	0	1	01	01	H5427_103_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	103	0	1	01	01	H5427_103_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	103	0	1	01	01	H5427_103_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	105	0	1	01	01	H5427_105_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	105	0	1	01	01	H5427_105_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	105	0	1	01	01	H5427_105_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	106	0	1	01	01	H5427_106_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	106	0	1	01	01	H5427_106_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	106	0	1	01	01	H5427_106_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	107	0	1	01	01	H5427_107_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	107	0	1	01	01	H5427_107_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	107	0	1	01	01	H5427_107_0	5			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	0	0	0	0	0	0	0	0	0				0		0
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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H5427	112	0	1	02	01	H5427_112_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	112	0	1	02	01	H5427_112_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	112	0	1	02	01	H5427_112_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	112	0	1	02	01	H5427_112_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5427	113	0	1	02	01	H5427_113_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	113	0	1	02	01	H5427_113_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5427	113	0	1	02	01	H5427_113_0	5			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	4			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	4			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	4			Preferred Brand	4	11	1	2	3	1		010	01	010		1				30					30						30		34								10.00							0.00							0.00																		10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	0.00			0.00			0.00						0.00		0.00	0			0			0						0		0
H5431	001	0	1	01	01	H5431_001_0	4			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	25			25			25						25		25
H5431	001	0	1	01	01	H5431_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	001	0	1	01	01	H5431_001_0	4			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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	006	0	1	01	01	H5431_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	006	0	1	01	01	H5431_006_0	5			Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	10.00																					10.00																		10.00				10.00		0.33			0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	10.00						10.00						10.00		10.00	25						25						25		25
H5431	006	0	1	01	01	H5431_006_0	5			Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		34	50.00																					50.00																		50.00				50.00		1.67			1.67			1.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5431	006	0	1	01	01	H5431_006_0	5			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, Supplemental Drugs																														
H5431	006	0	1	01	01	H5431_006_0	5			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	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																														
H5431	012	0	1	01	01	H5431_012_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																														
H5431	012	0	1	01	01	H5431_012_0	5			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	25			25			25						25		25
H5431	012	0	1	01	01	H5431_012_0	5			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	25			25			25						25		25
H5431	012	0	1	01	01	H5431_012_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																														
H5431	012	0	1	01	01	H5431_012_0	5			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	4			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	4			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	4			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	25			25			25						25		25
H5431	013	0	1	01	01	H5431_013_0	4			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	25			25			25						25		25
H5431	013	0	1	01	01	H5431_013_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	013	0	1	01	01	H5431_013_0	4			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	10.00																					10.00																		10.00				10.00		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	25						25						25		25
H5431	016	0	1	01	01	H5431_016_0	6		N	Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		34	50.00																					50.00																		50.00				50.00		1.67			1.67			1.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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					33																				33																	33			33								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	4			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	4			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	4			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	25			25			25						25		25
H5431	017	0	1	01	01	H5431_017_0	4			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	25			25			25						25		25
H5431	017	0	1	01	01	H5431_017_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	017	0	1	01	01	H5431_017_0	4			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	4			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	4			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	4			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	25			25			25						25		25
H5431	018	0	1	01	01	H5431_018_0	4			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	25			25			25						25		25
H5431	018	0	1	01	01	H5431_018_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	018	0	1	01	01	H5431_018_0	4			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	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	019	0	1	01	01	H5431_019_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	019	0	1	01	01	H5431_019_0	6		N	Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	10.00																					10.00																		10.00				10.00		0.33			0.33			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	10.00						10.00						10.00		10.00	25						25						25		25
H5431	019	0	1	01	01	H5431_019_0	6		N	Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		34	50.00																					50.00																		50.00				50.00		1.67			1.67			1.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5431	019	0	1	01	01	H5431_019_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	019	0	1	01	01	H5431_019_0	6		N	Supplemental Drugs	4	01	2	2	6	1	010		01	010		1	30								30						30		34	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	020	0	1	01	01	H5431_020_0	4			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	4			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	4			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	25			25			25						25		25
H5431	020	0	1	01	01	H5431_020_0	4			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	25			25			25						25		25
H5431	020	0	1	01	01	H5431_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5431	020	0	1	01	01	H5431_020_0	4			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	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																														
H5431	021	0	1	01	01	H5431_021_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																														
H5431	021	0	1	01	01	H5431_021_0	5			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	25			25			25						25		25
H5431	021	0	1	01	01	H5431_021_0	5			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	25			25			25						25		25
H5431	021	0	1	01	01	H5431_021_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																														
H5431	021	0	1	01	01	H5431_021_0	5			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	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																														
H5431	022	0	1	01	01	H5431_022_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																														
H5431	022	0	1	01	01	H5431_022_0	5			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	25			25			25						25		25
H5431	022	0	1	01	01	H5431_022_0	5			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	25			25			25						25		25
H5431	022	0	1	01	01	H5431_022_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																														
H5431	022	0	1	01	01	H5431_022_0	5			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	025	0	1	01	01	H5431_025_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	025	0	1	01	01	H5431_025_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	025	0	1	01	01	H5431_025_0	6		N	Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	5.00																					5.00																		5.00				5.00		0.17			0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	5.00						5.00						5.00		5.00	25						25						25		25
H5431	025	0	1	01	01	H5431_025_0	6		N	Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		34	50.00																					50.00																		50.00				50.00		1.67			1.67			1.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5431	025	0	1	01	01	H5431_025_0	6		N	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, Supplemental Drugs																														
H5431	025	0	1	01	01	H5431_025_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	026	0	1	01	01	H5431_026_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	026	0	1	01	01	H5431_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	0.00	0.00	0.00																			0.00	0.00	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	026	0	1	01	01	H5431_026_0	6		N	Preferred Brand	4	11	1	2	3	1	010		01	010		1	30								30						30		34	5.00																					5.00																		5.00				5.00		0.17			0.17			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	5.00						5.00						5.00		5.00	25						25						25		25
H5431	026	0	1	01	01	H5431_026_0	6		N	Non-Preferred Drug	4	11	1	2	4	1	010		01	010		1	30								30						30		34	50.00																					50.00																		50.00				50.00		1.67			1.67			1.47	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5431	026	0	1	01	01	H5431_026_0	6		N	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, Supplemental Drugs																														
H5431	026	0	1	01	01	H5431_026_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																														
H5433	001	0	1	01	01	H5433_001_0	4		N	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	Generic, Brand	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5433	001	0	1	01	01	H5433_001_0	4		N	Brand	4	10	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				97.75	25	25	25																				25															25			25								Generic, Brand	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H5434	002	0	1	04	01	H5434_002_0	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	002	0	1	04	01	H5434_002_0	9			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	002	0	1	04	01	H5434_002_0	9			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				41.54	20		20																		20		20															20			20								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	20		20				20		20				20		20
H5434	002	0	1	04	01	H5434_002_0	9			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				52.81	30		30																		30		30															30			30								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	25		25				25		25				25		25
H5434	002	0	1	04	01	H5434_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1173.24	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	25						25						25		25
H5434	002	0	1	04	01	H5434_002_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	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				42.17	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	21		21				21		21				21		21
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				60.47	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1137.71	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	25						25						25		25
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				47.03	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	21		21				21		21				21		21
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				54.63	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1516.50	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	25						25						25		25
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	0.00		0.00																			0.00		0.00																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 Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				48.84	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	21		21				21		21				21		21
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				46.40	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1115.39	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	25						25						25		25
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				52.22	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	21		21				21		21				21		21
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				56.81	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				985.02	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	25						25						25		25
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	9			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	030	0	1	04	01	H5434_030_0	9			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	030	0	1	04	01	H5434_030_0	9			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				51.24	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	21		21				21		21				21		21
H5434	030	0	1	04	01	H5434_030_0	9			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				53.46	30		30																		30		30															30			30								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	25		25				25		25				25		25
H5434	030	0	1	04	01	H5434_030_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1181.65	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	25						25						25		25
H5434	030	0	1	04	01	H5434_030_0	9			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	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	0.00		0.00																			0.00		0.00																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 Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				47.01	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	21		21				21		21				21		21
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				50.54	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				975.33	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	25						25						25		25
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				46.88	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	21		21				21		21				21		21
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				54.46	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1148.79	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	25						25						25		25
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	0.00		0.00																			0.00		0.00																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 Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				46.40	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	21		21				21		21				21		21
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				51.39	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				925.05	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	25						25						25		25
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				46.78	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	21		21				21		21				21		21
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				56.56	30		30																		30		30															30			30								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	25		25				25		25				25		25
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				1098.43	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	25						25						25		25
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	10			Preferred Generic	4	01	1	2	1	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	045	0	1	04	01	H5434_045_0	10			Generic	4	01	1	2	2	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5434	045	0	1	04	01	H5434_045_0	10			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				41.55	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	21		21				21		21				21		21
H5434	045	0	1	04	01	H5434_045_0	10			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				51.71	30		30																		30		30															30			30								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	25		25				25		25				25		25
H5434	045	0	1	04	01	H5434_045_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1338.65	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	25						25						25		25
H5434	045	0	1	04	01	H5434_045_0	10			Select Care Drugs	4	01	1	2	6	1	110		01	110		1	31		100				1	2	31		100				31		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5435	024	0	1	09	04	H5435_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																														
H5435	024	0	1	09	04	H5435_024_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5435	024	0	1	09	04	H5435_024_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H5435	024	0	1	09	04	H5435_024_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5435	024	0	1	09	04	H5435_024_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				341.00	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	25						25			25			25		25
H5439	011	0	1	04	01	H5439_011_0	12			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	011	0	1	04	01	H5439_011_0	12			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	011	0	1	04	01	H5439_011_0	12			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											95.31	25	25	25				95.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	011	0	1	04	01	H5439_011_0	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.58	41	41	41				78.58	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	011	0	1	04	01	H5439_011_0	12			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	011	0	1	04	01	H5439_011_0	12			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	015	0	1	04	01	H5439_015_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	015	0	1	04	01	H5439_015_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											110.30	25	25	25				110.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	015	0	1	04	01	H5439_015_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.68	50	50	50				78.68	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	015	0	1	04	01	H5439_015_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	015	0	1	04	01	H5439_015_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	10			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	019	0	1	04	01	H5439_019_0	10			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	019	0	1	04	01	H5439_019_0	10			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.69	25	25	25				100.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	019	0	1	04	01	H5439_019_0	10			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.83	34	34	34				70.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	019	0	1	04	01	H5439_019_0	10			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	019	0	1	04	01	H5439_019_0	10			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	1	1	04	01	H5439_022_1	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	022	1	1	04	01	H5439_022_1	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	022	1	1	04	01	H5439_022_1	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.08	25	25	25				119.08	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	1	1	04	01	H5439_022_1	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.79	36	36	36				67.79	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	1	1	04	01	H5439_022_1	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	1	1	04	01	H5439_022_1	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	2	1	04	01	H5439_022_2	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	022	2	1	04	01	H5439_022_2	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	022	2	1	04	01	H5439_022_2	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.08	25	25	25				119.08	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	2	1	04	01	H5439_022_2	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.79	36	36	36				67.79	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	2	1	04	01	H5439_022_2	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	2	1	04	01	H5439_022_2	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	3	1	04	01	H5439_022_3	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5439	022	3	1	04	01	H5439_022_3	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5439	022	3	1	04	01	H5439_022_3	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.08	25	25	25				119.08	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	3	1	04	01	H5439_022_3	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.79	36	36	36				67.79	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5439	022	3	1	04	01	H5439_022_3	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5439	022	3	1	04	01	H5439_022_3	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	6			Preferred Generic	4	01	1	2	1	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	0.00	0.00	0.00																			0.00	0.00	0.00																	0.00			0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5447	001	0	1	01	01	H5447_001_0	6			Generic	4	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	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	5.00	10.00	12.50				5.00	10.00	12.50				5.00		5.00	25	25	25				25	25	25				25		25
H5447	001	0	1	01	01	H5447_001_0	6			Preferred Brand	4	10	1	2	3	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31	47.00	94.00	117.50																			47.00	94.00	117.50																	47.00			47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5447	001	0	1	01	01	H5447_001_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				41.95	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5447	001	0	1	01	01	H5447_001_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				835.28	30																				30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5447	002	0	1	01	01	H5447_002_0	6		N	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 Drug, Specialty Tier																														
H5447	002	0	1	01	01	H5447_002_0	6		N	Generic	4	01	1	1	2	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				33.57	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5447	002	0	1	01	01	H5447_002_0	6		N	Preferred Brand	4	10	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				85.61	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5447	002	0	1	01	01	H5447_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					29	31				45.04	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	87.50				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5447	002	0	1	01	01	H5447_002_0	6		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							29	31				557.15	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5453	001	0	1	04	01	H5453_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	0	0	0				0	0	0				0		0
H5453	001	0	1	04	01	H5453_001_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	0	0	0				0	0	0				0		0
H5453	001	0	1	04	01	H5453_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				33.00	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	19	19	19				19	19	19				19		19
H5453	001	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	001	0	1	04	01	H5453_001_0	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	25						25						25		25
H5453	002	0	1	04	01	H5453_002_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	0	0	0				0	0	0				0		0
H5453	002	0	1	04	01	H5453_002_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	25	25	25				25	25	25				25		25
H5453	002	0	1	04	01	H5453_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				39.00	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	21	21	21				21	21	21				21		21
H5453	002	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	002	0	1	04	01	H5453_002_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	25						25						25		25
H5453	004	0	1	04	01	H5453_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	0	0	0				0	0	0				0		0
H5453	004	0	1	04	01	H5453_004_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5453	004	0	1	04	01	H5453_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				33.00	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	19	19	19				19	19	19				19		19
H5453	004	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	004	0	1	04	01	H5453_004_0	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	25						25						25		25
H5453	005	0	1	04	01	H5453_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5453	005	0	1	04	01	H5453_005_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	25	25	25				25	25	25				25		25
H5453	005	0	1	04	01	H5453_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				39.00	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	21	21	21				21	21	21				21		21
H5453	005	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	005	0	1	04	01	H5453_005_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	25						25						25		25
H5453	010	0	1	04	01	H5453_010_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	0	0	0				0	0	0				0		0
H5453	010	0	1	04	01	H5453_010_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5453	010	0	1	04	01	H5453_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				37.00	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	22	22	22				22	22	22				22		22
H5453	010	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	010	0	1	04	01	H5453_010_0	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	25						25						25		25
H5453	011	0	1	04	01	H5453_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5453	011	0	1	04	01	H5453_011_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	25	25	25				25	25	25				25		25
H5453	011	0	1	04	01	H5453_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				39.00	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	21	21	21				21	21	21				21		21
H5453	011	0	1	04	01	H5453_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				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	25	25	25				25	25	25				25		25
H5453	011	0	1	04	01	H5453_011_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	25						25						25		25
H5453	015	0	1	04	01	H5453_015_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5453	015	0	1	04	01	H5453_015_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5453	015	0	1	04	01	H5453_015_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H5453	015	0	1	04	01	H5453_015_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H5453	015	0	1	04	01	H5453_015_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5453	015	0	1	04	01	H5453_015_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5453	016	0	1	04	01	H5453_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5453	016	0	1	04	01	H5453_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5453	016	0	1	04	01	H5453_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5453	016	0	1	04	01	H5453_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H5453	016	0	1	04	01	H5453_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5453	016	0	1	04	01	H5453_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5453	017	0	1	04	01	H5453_017_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5453	017	0	1	04	01	H5453_017_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5453	017	0	1	04	01	H5453_017_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H5453	017	0	1	04	01	H5453_017_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H5453	017	0	1	04	01	H5453_017_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5453	017	0	1	04	01	H5453_017_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5453	018	0	1	04	01	H5453_018_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5453	018	0	1	04	01	H5453_018_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5453	018	0	1	04	01	H5453_018_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H5453	018	0	1	04	01	H5453_018_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H5453	018	0	1	04	01	H5453_018_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5453	018	0	1	04	01	H5453_018_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	001	0	1	01	01	H5454_001_0	9			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																														
H5454	001	0	1	01	01	H5454_001_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.17		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	001	0	1	01	01	H5454_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											63.11	20	20	20				63.11	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H5454	001	0	1	01	01	H5454_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											80.14	29	29	29				80.14	29	29	29										29	29	29				29	29	29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5454	001	0	1	01	01	H5454_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											805.95	30						805.95	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H5454	001	0	1	01	01	H5454_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				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																														
H5454	002	0	1	01	01	H5454_002_0	9			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								15.00	30.00	45.00					5.00	10.00	15.00											15.00	30.00	45.00				0.00	0.00	0.00				15.00				15.00			0.50	0.17		0.50	0.00	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	002	0	1	01	01	H5454_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											54.36	20	20	20				54.36	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H5454	002	0	1	01	01	H5454_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											87.18	31	31	31				87.18	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											883.23	30						883.23	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H5454	002	0	1	01	01	H5454_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	005	0	1	01	01	H5454_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	005	0	1	01	01	H5454_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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	005	0	1	01	01	H5454_005_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											53.53	20	20	20				53.53	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H5454	005	0	1	01	01	H5454_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											87.75	34	34	34				87.75	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5454	005	0	1	01	01	H5454_005_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											848.81	31						848.81	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H5454	005	0	1	01	01	H5454_005_0	7			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	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																														
H5454	006	0	1	01	01	H5454_006_0	8			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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5454	006	0	1	01	01	H5454_006_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.53	20	20	20				54.53	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H5454	006	0	1	01	01	H5454_006_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											92.73	35	35	35				92.73	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											850.32	29						850.32	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H5454	006	0	1	01	01	H5454_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5471	064	0	1	01	01	H5471_064_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	0.00	0.00	0.00																			0.00	0.00	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	064	0	1	01	01	H5471_064_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				117.00	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	25	25	25				25	25	25				25		25
H5471	064	0	1	01	01	H5471_064_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				130.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	064	0	1	01	01	H5471_064_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	064	0	1	01	01	H5471_064_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	065	0	1	01	01	H5471_065_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	065	0	1	01	01	H5471_065_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	065	0	1	01	01	H5471_065_0	5			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	0	0	0	0	0	0	0	0	0				0		0
H5471	065	0	1	01	01	H5471_065_0	5			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	25			25			25						25		25
H5471	065	0	1	01	01	H5471_065_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	065	0	1	01	01	H5471_065_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	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	0.00	0.00	0.00																			0.00	0.00	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	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																														
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				98.00	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	25	25	25				25	25	25				25		25
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				127.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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	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	0	0	0	0	0	0	0	0	0				0		0
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	25			25			25						25		25
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	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	070	0	1	01	01	H5471_070_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	070	0	1	01	01	H5471_070_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	20.00	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	25	25	25	25	25	25	25	25	25				25		25
H5471	070	0	1	01	01	H5471_070_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	25			25			25						25		25
H5471	070	0	1	01	01	H5471_070_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	070	0	1	01	01	H5471_070_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	071	0	1	01	01	H5471_071_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	071	0	1	01	01	H5471_071_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	071	0	1	01	01	H5471_071_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5471	071	0	1	01	01	H5471_071_0	5			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	25			25			25						25		25
H5471	071	0	1	01	01	H5471_071_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	071	0	1	01	01	H5471_071_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	072	0	1	01	01	H5471_072_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				109.00	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	25	25	25				25	25	25				25		25
H5471	072	0	1	01	01	H5471_072_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				119.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	072	0	1	01	01	H5471_072_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	072	0	1	01	01	H5471_072_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	073	0	1	01	01	H5471_073_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	073	0	1	01	01	H5471_073_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	073	0	1	01	01	H5471_073_0	5			Preferred Brand	4	11	1	2	3	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	60.00																20.00				20.00			0.67	0.67	0.67			0.59	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	40.00	60.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
H5471	073	0	1	01	01	H5471_073_0	5			Non-Preferred Drug	4	11	1	2	4	1		010	01	010		1				30					30						30		34								70.00							65.00							65.00																		70.00				70.00			2.33	2.17	2.17			2.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H5471	073	0	1	01	01	H5471_073_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	073	0	1	01	01	H5471_073_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	074	0	1	01	01	H5471_074_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	074	0	1	01	01	H5471_074_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	074	0	1	01	01	H5471_074_0	5			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	90.00	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	25	25	25	25	25	25	25	25	25				25		25
H5471	074	0	1	01	01	H5471_074_0	5			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	25			25			25						25		25
H5471	074	0	1	01	01	H5471_074_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	074	0	1	01	01	H5471_074_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	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	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
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	7		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																														
H5471	076	0	1	01	01	H5471_076_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				120.00	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	25	25	25				25	25	25				25		25
H5471	076	0	1	01	01	H5471_076_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				119.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	076	0	1	01	01	H5471_076_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	076	0	1	01	01	H5471_076_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	077	0	1	01	01	H5471_077_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	077	0	1	01	01	H5471_077_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	077	0	1	01	01	H5471_077_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	25	25	25	25	25	25	25	25	25				25		25
H5471	077	0	1	01	01	H5471_077_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	25			25			25						25		25
H5471	077	0	1	01	01	H5471_077_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	077	0	1	01	01	H5471_077_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	078	0	1	01	01	H5471_078_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	078	0	1	01	01	H5471_078_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	078	0	1	01	01	H5471_078_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								35.00	70.00	105.00					35.00	70.00	105.00					35.00	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	25	25	25	25	25	25	25	25	25				25		25
H5471	078	0	1	01	01	H5471_078_0	5			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	25			25			25						25		25
H5471	078	0	1	01	01	H5471_078_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	078	0	1	01	01	H5471_078_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	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	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
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	7		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																														
H5471	082	0	1	01	01	H5471_082_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				10.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				103.00	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	25	25	25				25	25	25				25		25
H5471	082	0	1	01	01	H5471_082_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				114.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	082	0	1	01	01	H5471_082_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	082	0	1	01	01	H5471_082_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	084	0	1	01	01	H5471_084_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	0.00	0.00	0.00																			0.00	0.00	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	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.00	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				104.00	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	25	25	25				25	25	25				25		25
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				133.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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	110	0	1	01	01	H5471_110_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	110	0	1	01	01	H5471_110_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	110	0	1	01	01	H5471_110_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	25	25	25	25	25	25	25	25	25				25		25
H5471	110	0	1	01	01	H5471_110_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	25			25			25						25		25
H5471	110	0	1	01	01	H5471_110_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	110	0	1	01	01	H5471_110_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	111	0	1	01	01	H5471_111_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				5.00	25	25	25																		25	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	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	25	25	25				25	25	25				25		25
H5471	111	0	1	01	01	H5471_111_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				115.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	111	0	1	01	01	H5471_111_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	111	0	1	01	01	H5471_111_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	112	0	1	01	01	H5471_112_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	112	0	1	01	01	H5471_112_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	112	0	1	01	01	H5471_112_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	25	25	25	25	25	25	25	25	25				25		25
H5471	112	0	1	01	01	H5471_112_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	25			25			25						25		25
H5471	112	0	1	01	01	H5471_112_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	112	0	1	01	01	H5471_112_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	113	0	1	01	01	H5471_113_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	113	0	1	01	01	H5471_113_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	113	0	1	01	01	H5471_113_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5471	113	0	1	01	01	H5471_113_0	5			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	25			25			25						25		25
H5471	113	0	1	01	01	H5471_113_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	113	0	1	01	01	H5471_113_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	114	0	1	01	01	H5471_114_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	114	0	1	01	01	H5471_114_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	114	0	1	01	01	H5471_114_0	5			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	0	0	0	0	0	0	0	0	0				0		0
H5471	114	0	1	01	01	H5471_114_0	5			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	25			25			25						25		25
H5471	114	0	1	01	01	H5471_114_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	114	0	1	01	01	H5471_114_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	115	0	1	01	01	H5471_115_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				106.00	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	25	25	25				25	25	25				25		25
H5471	115	0	1	01	01	H5471_115_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				131.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	115	0	1	01	01	H5471_115_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	115	0	1	01	01	H5471_115_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	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								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	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
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	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	117	0	1	01	01	H5471_117_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	117	0	1	01	01	H5471_117_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								40.00	80.00	120.00					40.00	80.00	120.00					40.00	120.00	120.00																40.00				40.00			1.33	1.33	1.33			1.18	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	25	25	25	25	25	25	25	25	25				25		25
H5471	117	0	1	01	01	H5471_117_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	25			25			25						25		25
H5471	117	0	1	01	01	H5471_117_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	117	0	1	01	01	H5471_117_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	118	0	1	01	01	H5471_118_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				100.00	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	25	25	25				25	25	25				25		25
H5471	118	0	1	01	01	H5471_118_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				99.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	118	0	1	01	01	H5471_118_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	118	0	1	01	01	H5471_118_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	119	0	1	01	01	H5471_119_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	119	0	1	01	01	H5471_119_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	119	0	1	01	01	H5471_119_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	25	25	25	25	25	25	25	25	25				25		25
H5471	119	0	1	01	01	H5471_119_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	25			25			25						25		25
H5471	119	0	1	01	01	H5471_119_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	119	0	1	01	01	H5471_119_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	120	0	1	01	01	H5471_120_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	120	0	1	01	01	H5471_120_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	120	0	1	01	01	H5471_120_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	25	25	25	25	25	25	25	25	25				25		25
H5471	120	0	1	01	01	H5471_120_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	25			25			25						25		25
H5471	120	0	1	01	01	H5471_120_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	120	0	1	01	01	H5471_120_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	121	0	1	01	01	H5471_121_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				107.00	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	25	25	25				25	25	25				25		25
H5471	121	0	1	01	01	H5471_121_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				122.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	121	0	1	01	01	H5471_121_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	121	0	1	01	01	H5471_121_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	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								20.00	40.00	60.00					20.00	40.00	60.00					20.00	40.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
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								70.00							65.00							65.00																		70.00				70.00			2.33	2.17	2.17			2.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
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	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	123	0	1	01	01	H5471_123_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	123	0	1	01	01	H5471_123_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	25	25	25	25	25	25	25	25	25				25		25
H5471	123	0	1	01	01	H5471_123_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	25			25			25						25		25
H5471	123	0	1	01	01	H5471_123_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	123	0	1	01	01	H5471_123_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	124	0	1	01	01	H5471_124_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	124	0	1	01	01	H5471_124_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	124	0	1	01	01	H5471_124_0	5			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								20.00	40.00	60.00					20.00	40.00	60.00					20.00	60.00	60.00																20.00				20.00			0.67	0.67	0.67			0.59	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
H5471	124	0	1	01	01	H5471_124_0	5			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	25			25			25						25		25
H5471	124	0	1	01	01	H5471_124_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	124	0	1	01	01	H5471_124_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	125	0	1	01	01	H5471_125_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	0.00	0.00	0.00																			0.00	0.00	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	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.00	25	25	25																		25	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	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				105.00	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	25	25	25				25	25	25				25		25
H5471	125	0	1	01	01	H5471_125_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				138.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	125	0	1	01	01	H5471_125_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	125	0	1	01	01	H5471_125_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	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	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
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																														
H5471	127	0	1	01	01	H5471_127_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	0.00	0.00	0.00																			0.00	0.00	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	127	0	1	01	01	H5471_127_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	127	0	1	01	01	H5471_127_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				117.00	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	25	25	25				25	25	25				25		25
H5471	127	0	1	01	01	H5471_127_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				130.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	127	0	1	01	01	H5471_127_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	127	0	1	01	01	H5471_127_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	128	0	1	01	01	H5471_128_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	0.00	0.00	0.00																			0.00	0.00	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	128	0	1	01	01	H5471_128_0	7		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																														
H5471	128	0	1	01	01	H5471_128_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				100.00	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	25	25	25				25	25	25				25		25
H5471	128	0	1	01	01	H5471_128_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				127.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	128	0	1	01	01	H5471_128_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	128	0	1	01	01	H5471_128_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	129	0	1	01	01	H5471_129_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	0.00	0.00	0.00																			0.00	0.00	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	129	0	1	01	01	H5471_129_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	129	0	1	01	01	H5471_129_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				110.00	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	25	25	25				25	25	25				25		25
H5471	129	0	1	01	01	H5471_129_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				119.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	129	0	1	01	01	H5471_129_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	129	0	1	01	01	H5471_129_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	130	0	1	01	01	H5471_130_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	0.00	0.00	0.00																			0.00	0.00	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	130	0	1	01	01	H5471_130_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	130	0	1	01	01	H5471_130_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				120.00	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	25	25	25				25	25	25				25		25
H5471	130	0	1	01	01	H5471_130_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				121.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	130	0	1	01	01	H5471_130_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	130	0	1	01	01	H5471_130_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	131	0	1	01	01	H5471_131_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	0.00	0.00	0.00																			0.00	0.00	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	131	0	1	01	01	H5471_131_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				10.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	131	0	1	01	01	H5471_131_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				103.00	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	25	25	25				25	25	25				25		25
H5471	131	0	1	01	01	H5471_131_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				113.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	131	0	1	01	01	H5471_131_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	131	0	1	01	01	H5471_131_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	132	0	1	01	01	H5471_132_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	0.00	0.00	0.00																			0.00	0.00	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	132	0	1	01	01	H5471_132_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	132	0	1	01	01	H5471_132_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				107.00	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	25	25	25				25	25	25				25		25
H5471	132	0	1	01	01	H5471_132_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				134.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	132	0	1	01	01	H5471_132_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	132	0	1	01	01	H5471_132_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	133	0	1	01	01	H5471_133_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	0.00	0.00	0.00																			0.00	0.00	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	133	0	1	01	01	H5471_133_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	133	0	1	01	01	H5471_133_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				95.00	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	25	25	25				25	25	25				25		25
H5471	133	0	1	01	01	H5471_133_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				116.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	133	0	1	01	01	H5471_133_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	133	0	1	01	01	H5471_133_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	134	0	1	01	01	H5471_134_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	0.00	0.00	0.00																			0.00	0.00	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	134	0	1	01	01	H5471_134_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	134	0	1	01	01	H5471_134_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				106.00	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	25	25	25				25	25	25				25		25
H5471	134	0	1	01	01	H5471_134_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				131.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	134	0	1	01	01	H5471_134_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	134	0	1	01	01	H5471_134_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	135	0	1	01	01	H5471_135_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	0.00	0.00	0.00																			0.00	0.00	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	135	0	1	01	01	H5471_135_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				8.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	135	0	1	01	01	H5471_135_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				105.00	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	25	25	25				25	25	25				25		25
H5471	135	0	1	01	01	H5471_135_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				104.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	135	0	1	01	01	H5471_135_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	135	0	1	01	01	H5471_135_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	136	0	1	01	01	H5471_136_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	0.00	0.00	0.00																			0.00	0.00	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	136	0	1	01	01	H5471_136_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	136	0	1	01	01	H5471_136_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				107.00	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	25	25	25				25	25	25				25		25
H5471	136	0	1	01	01	H5471_136_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				122.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	136	0	1	01	01	H5471_136_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	136	0	1	01	01	H5471_136_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	137	0	1	01	01	H5471_137_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	0.00	0.00	0.00																			0.00	0.00	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	137	0	1	01	01	H5471_137_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				7.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	137	0	1	01	01	H5471_137_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				105.00	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	25	25	25				25	25	25				25		25
H5471	137	0	1	01	01	H5471_137_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				137.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	137	0	1	01	01	H5471_137_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	137	0	1	01	01	H5471_137_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	138	0	1	01	01	H5471_138_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	0.00	0.00	0.00																			0.00	0.00	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	138	0	1	01	01	H5471_138_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	138	0	1	01	01	H5471_138_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				91.00	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	25	25	25				25	25	25				25		25
H5471	138	0	1	01	01	H5471_138_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				107.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	138	0	1	01	01	H5471_138_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	138	0	1	01	01	H5471_138_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	139	0	1	01	01	H5471_139_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	0.00	0.00	0.00																			0.00	0.00	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	139	0	1	01	01	H5471_139_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				5.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	139	0	1	01	01	H5471_139_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				91.00	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	25	25	25				25	25	25				25		25
H5471	139	0	1	01	01	H5471_139_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				107.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	139	0	1	01	01	H5471_139_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	139	0	1	01	01	H5471_139_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	140	0	1	01	01	H5471_140_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	0.00	0.00	0.00																			0.00	0.00	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	140	0	1	01	01	H5471_140_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	140	0	1	01	01	H5471_140_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				98.00	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	25	25	25				25	25	25				25		25
H5471	140	0	1	01	01	H5471_140_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				118.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	140	0	1	01	01	H5471_140_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	140	0	1	01	01	H5471_140_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	141	0	1	01	01	H5471_141_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	0.00	0.00	0.00																			0.00	0.00	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	141	0	1	01	01	H5471_141_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	141	0	1	01	01	H5471_141_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				98.00	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	25	25	25				25	25	25				25		25
H5471	141	0	1	01	01	H5471_141_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				118.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	141	0	1	01	01	H5471_141_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	141	0	1	01	01	H5471_141_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	142	0	1	01	01	H5471_142_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	0.00	0.00	0.00																			0.00	0.00	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	142	0	1	01	01	H5471_142_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	142	0	1	01	01	H5471_142_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				97.00	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	25	25	25				25	25	25				25		25
H5471	142	0	1	01	01	H5471_142_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				116.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	142	0	1	01	01	H5471_142_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	142	0	1	01	01	H5471_142_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	143	0	1	01	01	H5471_143_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	0.00	0.00	0.00																			0.00	0.00	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	143	0	1	01	01	H5471_143_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				6.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H5471	143	0	1	01	01	H5471_143_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				96.00	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	25	25	25				25	25	25				25		25
H5471	143	0	1	01	01	H5471_143_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		34				116.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5471	143	0	1	01	01	H5471_143_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	143	0	1	01	01	H5471_143_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																														
H5472	001	0	1	02	01	H5472_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	001	0	1	02	01	H5472_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	001	0	1	02	01	H5472_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	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	25	25	25				25	25	25				25		25
H5472	001	0	1	02	01	H5472_001_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.75	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		35.00	25	25	25				25	25	25				25		25
H5472	001	0	1	02	01	H5472_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				615.02	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	7			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	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	25	25	25				25	25	25				25		25
H5472	002	0	1	02	01	H5472_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	002	0	1	02	01	H5472_002_0	7			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	25	25	25				25	25	25				25		25
H5472	002	0	1	02	01	H5472_002_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				38.47	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		35.00	25	25	25				25	25	25				25		25
H5472	002	0	1	02	01	H5472_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				540.57	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	7			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	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	25	25	25				25	25	25				25		25
H5472	003	0	1	02	01	H5472_003_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	25	25	25				25	25	25				25		25
H5472	003	0	1	02	01	H5472_003_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	25	25	25				25	25	25				25		25
H5472	003	0	1	02	01	H5472_003_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				51.16	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		35.00	25	25	25				25	25	25				25		25
H5472	003	0	1	02	01	H5472_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				480.08	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	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																														
H5472	004	0	1	02	01	H5472_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	004	0	1	02	01	H5472_004_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.06	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		35.00	25	25	25				25	25	25				25		25
H5472	004	0	1	02	01	H5472_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				78.21	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5472	004	0	1	02	01	H5472_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				52.83	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		35.00	25	25	25				25	25	25				25		25
H5472	004	0	1	02	01	H5472_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				433.19	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	004	0	1	02	01	H5472_004_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	007	0	1	02	01	H5472_007_0	7		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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	007	0	1	02	01	H5472_007_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				6.39	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		35.00	25	25	25				25	25	25				25		25
H5472	007	0	1	02	01	H5472_007_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				72.31	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5472	007	0	1	02	01	H5472_007_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				36.61	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5472	007	0	1	02	01	H5472_007_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				488.14	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	007	0	1	02	01	H5472_007_0	7		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	009	0	1	02	01	H5472_009_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	009	0	1	02	01	H5472_009_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				6.33	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		35.00	25	25	25				25	25	25				25		25
H5472	009	0	1	02	01	H5472_009_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				71.62	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		35.00	25	25	25				25	25	25				25		25
H5472	009	0	1	02	01	H5472_009_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				36.41	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5472	009	0	1	02	01	H5472_009_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				483.15	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	009	0	1	02	01	H5472_009_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	010	0	1	02	01	H5472_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	25	25	25				25	25	25				25		25
H5472	010	0	1	02	01	H5472_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H5472	010	0	1	02	01	H5472_010_0	7			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	25	25	25				25	25	25				25		25
H5472	010	0	1	02	01	H5472_010_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				82.68	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		35.00	25	25	25				25	25	25				25		25
H5472	010	0	1	02	01	H5472_010_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				485.38	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5472	010	0	1	02	01	H5472_010_0	7			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	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	001	0	1	02	01	H5475_001_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9		N	Preferred Brand	3	11	1	2	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					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	105.00		70.00	105.00		70.00	94.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	001	0	1	02	01	H5475_001_0	9		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											49.31	42	42	42				49.31	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	001	0	1	02	01	H5475_001_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5475	026	0	1	02	01	H5475_026_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5475	026	0	1	02	01	H5475_026_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											121.70	25	25	25				121.70	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	026	0	1	02	01	H5475_026_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											56.29	49	49	49				56.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	026	0	1	02	01	H5475_026_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	026	0	1	02	01	H5475_026_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5475	031	0	1	02	01	H5475_031_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5475	031	0	1	02	01	H5475_031_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.48	25	25	25				122.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	031	0	1	02	01	H5475_031_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											60.78	36	36	36				60.78	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	031	0	1	02	01	H5475_031_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	031	0	1	02	01	H5475_031_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	038	0	1	02	01	H5475_038_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											85.84	20	20	20				85.84	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5475	038	0	1	02	01	H5475_038_0	9			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											37.43	34	34	34				37.43	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	038	0	1	02	01	H5475_038_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	039	0	1	02	01	H5475_039_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5475	039	0	1	02	01	H5475_039_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											98.75	25	25	25				98.75	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	039	0	1	02	01	H5475_039_0	9		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5475	039	0	1	02	01	H5475_039_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								3.00	6.00	9.00					0.00	0.00	0.00												6.00	9.00					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																														
H5496	005	0	1	01	01	H5496_005_0	5			Preferred Generic	4	11	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																														
H5496	005	0	1	01	01	H5496_005_0	5			Generic	4	11	1	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	0		0						0				0		0
H5496	005	0	1	01	01	H5496_005_0	5			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	45.00		110.00																					90.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H5496	005	0	1	01	01	H5496_005_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	90.00		225.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H5496	005	0	1	01	01	H5496_005_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				754.47	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5496	005	0	1	01	01	H5496_005_0	5			Select Care Drugs	4	10	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	3.00		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	012	0	1	01	01	H5496_012_0	5			Preferred Generic	4	11	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																														
H5496	012	0	1	01	01	H5496_012_0	5			Generic	4	11	1	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	0		0						0				0		0
H5496	012	0	1	01	01	H5496_012_0	5			Preferred Brand	4	11	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	45.00		110.00																					90.00																45.00				45.00		1.50						1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H5496	012	0	1	01	01	H5496_012_0	5			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	90.00		225.00																					180.00																90.00				90.00		3.00						2.90	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H5496	012	0	1	01	01	H5496_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				803.90	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											76.76	24	24	24				99.40	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.56	25	25	25				45.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											564.57	25						623.23	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	25			25			25			25			25		25
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											73.51	24	24	24				93.46	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.35	25	25	25				46.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											526.38	25						601.96	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	25			25			25			25			25		25
H5521	020	0	1	04	01	H5521_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																														
H5521	020	0	1	04	01	H5521_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																														
H5521	020	0	1	04	01	H5521_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											58.02	22	22	22				79.03	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	020	0	1	04	01	H5521_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											42.82	25	25	25				42.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	020	0	1	04	01	H5521_020_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											504.59	27						575.88	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	25			25			25			25			25		25
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											63.80	24	24	24				84.20	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											46.03	25	25	25				42.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											470.53	25						514.27	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	25			25			25			25			25		25
H5521	033	0	1	04	01	H5521_033_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.51	24	24	24				88.33	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	033	0	1	04	01	H5521_033_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											50.30	25	25	25				46.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	033	0	1	04	01	H5521_033_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											534.26	25						528.83	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	25			25			25			25			25		25
H5521	037	0	1	04	01	H5521_037_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	037	0	1	04	01	H5521_037_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	037	0	1	04	01	H5521_037_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.50	22	22	22				84.33	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	037	0	1	04	01	H5521_037_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											47.49	25	25	25				47.44	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	037	0	1	04	01	H5521_037_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											534.18	27						558.51	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	25			25			25			25			25		25
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											65.29	24	24	24				90.88	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											50.19	25	25	25				45.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.51	25						577.86	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	25			25			25			25			25		25
H5521	077	0	1	04	01	H5521_077_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	077	0	1	04	01	H5521_077_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	077	0	1	04	01	H5521_077_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.60	24	24	24				100.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	077	0	1	04	01	H5521_077_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											41.74	25	25	25				46.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	077	0	1	04	01	H5521_077_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											574.38	25						655.84	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	25			25			25			25			25		25
H5521	081	0	1	04	01	H5521_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																														
H5521	081	0	1	04	01	H5521_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																														
H5521	081	0	1	04	01	H5521_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											57.66	22	22	22				87.91	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	081	0	1	04	01	H5521_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											39.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	081	0	1	04	01	H5521_081_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.75	27						615.41	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	25			25			25			25			25		25
H5521	084	0	1	04	01	H5521_084_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.89	24	24	24				90.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	084	0	1	04	01	H5521_084_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.77	25	25	25				47.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	084	0	1	04	01	H5521_084_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											490.20	25						575.88	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	25			25			25			25			25		25
H5521	085	0	1	04	01	H5521_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																														
H5521	085	0	1	04	01	H5521_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																														
H5521	085	0	1	04	01	H5521_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											70.14	24	24	24				92.22	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	085	0	1	04	01	H5521_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											36.21	25	25	25				42.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	085	0	1	04	01	H5521_085_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											512.65	25						663.21	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	25			25			25			25			25		25
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											77.37	24	24	24				101.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											48.07	25	25	25				43.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											580.74	25						564.91	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	25			25			25			25			25		25
H5521	087	0	1	04	01	H5521_087_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	087	0	1	04	01	H5521_087_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.06	22	22	22				84.15	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	087	0	1	04	01	H5521_087_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.66	25	25	25				45.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	087	0	1	04	01	H5521_087_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											511.85	27						584.78	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											70.76	24	24	24				98.53	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.91	25	25	25				44.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											502.92	25						621.74	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	25			25			25			25			25		25
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											68.26	24	24	24				95.99	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.22	25	25	25				44.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											510.15	25						625.85	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	25			25			25			25			25		25
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											71.30	24	24	24				97.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.01	25	25	25				44.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											536.71	25						594.14	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	25			25			25			25			25		25
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											59.77	24	24	24				90.29	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.08	25	25	25				41.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											539.63	25						615.33	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	25			25			25			25			25		25
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											62.73	24	24	24				98.99	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.79	25	25	25				47.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											574.37	25						553.02	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	25			25			25			25			25		25
H5521	116	0	1	04	01	H5521_116_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	116	0	1	04	01	H5521_116_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	116	0	1	04	01	H5521_116_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											75.24	24	24	24				97.37	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	116	0	1	04	01	H5521_116_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											35.82	25	25	25				43.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	116	0	1	04	01	H5521_116_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											534.86	25						642.37	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	25			25			25			25			25		25
H5521	119	0	1	04	01	H5521_119_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	119	0	1	04	01	H5521_119_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	119	0	1	04	01	H5521_119_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.67	24	24	24				100.59	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	119	0	1	04	01	H5521_119_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											42.03	25	25	25				47.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	119	0	1	04	01	H5521_119_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											583.45	25						650.39	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	25			25			25			25			25		25
H5521	120	0	1	04	01	H5521_120_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	120	0	1	04	01	H5521_120_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	120	0	1	04	01	H5521_120_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											89.36	24	24	24				106.01	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	120	0	1	04	01	H5521_120_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											56.28	25	25	25				51.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	120	0	1	04	01	H5521_120_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											535.53	25						609.51	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	25			25			25			25			25		25
H5521	121	0	1	04	01	H5521_121_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	121	0	1	04	01	H5521_121_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	121	0	1	04	01	H5521_121_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											84.29	24	24	24				105.54	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	121	0	1	04	01	H5521_121_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											49.78	25	25	25				51.47	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	121	0	1	04	01	H5521_121_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											496.41	25						634.45	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											60.51	24	24	24				86.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.98	25	25	25				46.66	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											598.86	25						596.43	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	25			25			25			25			25		25
H5521	123	0	1	04	01	H5521_123_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	123	0	1	04	01	H5521_123_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	123	0	1	04	01	H5521_123_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.46	22	22	22				85.38	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	123	0	1	04	01	H5521_123_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											45.97	25	25	25				48.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	123	0	1	04	01	H5521_123_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											581.37	27						765.59	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	25			25			25			25			25		25
H5521	124	0	1	04	01	H5521_124_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	124	0	1	04	01	H5521_124_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	124	0	1	04	01	H5521_124_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.26	24	24	24				102.63	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	124	0	1	04	01	H5521_124_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											44.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	124	0	1	04	01	H5521_124_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											620.29	25						744.18	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											71.60	24	24	24				94.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.65	25	25	25				43.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											519.73	25						563.87	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	25			25			25			25			25		25
H5521	140	0	1	04	01	H5521_140_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	140	0	1	04	01	H5521_140_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.74	22	22	22				89.36	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	140	0	1	04	01	H5521_140_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.14	25	25	25				42.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	140	0	1	04	01	H5521_140_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											589.97	27						579.69	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											68.88	24	24	24				91.32	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.69	25	25	25				42.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											486.27	25						620.07	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											66.25	24	24	24				95.17	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.03	25	25	25				43.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											530.31	25						717.62	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	25			25			25			25			25		25
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											67.30	24	24	24				90.46	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.39	25	25	25				42.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											563.10	25						574.16	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	25			25			25			25			25		25
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											67.98	24	24	24				94.88	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											47.05	25	25	25				50.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											498.05	25						573.75	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	25			25			25			25			25		25
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											81.64	24	24	24				100.36	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.02	25	25	25				46.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											510.88	25						521.75	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											69.52	22	22	22				89.93	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											37.31	25	25	25				44.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											590.91	27						604.70	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											69.85	24	24	24				94.06	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.39	25	25	25				44.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											557.90	25						555.77	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											63.39	22	22	22				85.75	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											40.78	25	25	25				42.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											547.57	27						652.23	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	25			25			25			25			25		25
H5521	171	0	1	04	01	H5521_171_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.53	24	24	24				94.66	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	171	0	1	04	01	H5521_171_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											35.17	25	25	25				41.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	171	0	1	04	01	H5521_171_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											511.80	25						575.90	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	25			25			25			25			25		25
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											67.29	24	24	24				92.61	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.57	25	25	25				46.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											552.76	25						576.06	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	25			25			25			25			25		25
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											72.82	24	24	24				99.58	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											462.16	25						771.23	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	25			25			25			25			25		25
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											65.64	24	24	24				92.12	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.27	25	25	25				46.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											607.68	25						744.36	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	25			25			25			25			25		25
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											62.15	24	24	24				86.79	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.96	25	25	25				41.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											521.09	25						725.41	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	25			25			25			25			25		25
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											73.95	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.79	25	25	25				43.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											512.52	25						558.61	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	25			25			25			25			25		25
H5521	215	0	1	04	01	H5521_215_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	215	0	1	04	01	H5521_215_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	215	0	1	04	01	H5521_215_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											82.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	215	0	1	04	01	H5521_215_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											40.72	25	25	25				49.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	215	0	1	04	01	H5521_215_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											556.71	25						709.77	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	25			25			25			25			25		25
H5521	218	0	1	04	01	H5521_218_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	218	0	1	04	01	H5521_218_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	218	0	1	04	01	H5521_218_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				94.22	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	218	0	1	04	01	H5521_218_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				43.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	218	0	1	04	01	H5521_218_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											544.74	25						606.57	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	25			25			25			25			25		25
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											72.64	24	24	24				93.41	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.87	25	25	25				43.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											538.83	25						651.05	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	25			25			25			25			25		25
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											64.54	24	24	24				94.52	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.40	25	25	25				44.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											515.40	25						515.04	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	25			25			25			25			25		25
H5521	224	0	1	04	01	H5521_224_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.06	24	24	24				91.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	224	0	1	04	01	H5521_224_0	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				44.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	224	0	1	04	01	H5521_224_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											535.02	25						643.52	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	25			25			25			25			25		25
H5521	227	0	1	04	01	H5521_227_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.14	24	24	24				91.27	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	227	0	1	04	01	H5521_227_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.80	25	25	25				39.97	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	227	0	1	04	01	H5521_227_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											503.09	25						611.40	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	25			25			25			25			25		25
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											60.84	24	24	24				93.17	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.23	25	25	25				44.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											504.63	25						569.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											75.70	24	24	24				92.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.65	25	25	25				46.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											486.76	25						602.85	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											78.87	24	24	24				90.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											49.62	25	25	25				37.62	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											603.67	25						502.11	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											75.53	24	24	24				94.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.05	25	25	25				41.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											511.90	25						530.10	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	25			25			25			25			25		25
H5521	245	0	1	04	01	H5521_245_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	245	0	1	04	01	H5521_245_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.12	24	24	24				91.79	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	245	0	1	04	01	H5521_245_0	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				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	245	0	1	04	01	H5521_245_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											545.58	25						668.00	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	25			25			25			25			25		25
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											60.94	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.42	25	25	25				43.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											550.73	25						638.95	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	25			25			25			25			25		25
H5521	249	0	1	04	01	H5521_249_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	249	0	1	04	01	H5521_249_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.30	24	24	24				92.43	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	249	0	1	04	01	H5521_249_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	249	0	1	04	01	H5521_249_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.02	25						685.70	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	25			25			25			25			25		25
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											59.43	24	24	24				87.95	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.28	25	25	25				43.86	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											597.61	25						650.61	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	25			25			25			25			25		25
H5521	251	0	1	04	01	H5521_251_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	251	0	1	04	01	H5521_251_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.90	24	24	24				93.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	251	0	1	04	01	H5521_251_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	251	0	1	04	01	H5521_251_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											515.14	25						602.81	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											69.24	24	24	24				88.15	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.70	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											490.31	25						563.19	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	25			25			25			25			25		25
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											67.44	24	24	24				90.30	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.19	25	25	25				43.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											512.70	25						563.80	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	25			25			25			25			25		25
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											56.66	24	24	24				88.65	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											34.54	25	25	25				40.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											462.71	25						621.91	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	25			25			25			25			25		25
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											62.21	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.85	25	25	25				47.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											522.01	25						620.64	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	25			25			25			25			25		25
H5521	269	0	1	04	01	H5521_269_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.65	24	24	24				94.71	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	269	0	1	04	01	H5521_269_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											45.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	269	0	1	04	01	H5521_269_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											489.42	25						529.46	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	25			25			25			25			25		25
H5521	270	0	1	04	01	H5521_270_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.09	24	24	24				95.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	270	0	1	04	01	H5521_270_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.82	25	25	25				44.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	270	0	1	04	01	H5521_270_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											564.09	25						586.08	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	25			25			25			25			25		25
H5521	271	0	1	04	01	H5521_271_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.99	24	24	24				96.65	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	271	0	1	04	01	H5521_271_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.40	25	25	25				44.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	271	0	1	04	01	H5521_271_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											498.98	25						632.87	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	25			25			25			25			25		25
H5521	272	0	1	04	01	H5521_272_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.86	24	24	24				95.69	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	272	0	1	04	01	H5521_272_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.27	25	25	25				45.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	272	0	1	04	01	H5521_272_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											554.56	25						544.29	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	25			25			25			25			25		25
H5521	273	0	1	04	01	H5521_273_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.26	24	24	24				93.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	273	0	1	04	01	H5521_273_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											48.29	25	25	25				47.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	273	0	1	04	01	H5521_273_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											562.06	25						538.22	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	25			25			25			25			25		25
H5521	275	0	1	04	01	H5521_275_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	275	0	1	04	01	H5521_275_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	275	0	1	04	01	H5521_275_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											80.47	24	24	24				105.20	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	275	0	1	04	01	H5521_275_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				48.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	275	0	1	04	01	H5521_275_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											525.51	25						726.84	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	25			25			25			25			25		25
H5521	277	0	1	04	01	H5521_277_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	277	0	1	04	01	H5521_277_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	277	0	1	04	01	H5521_277_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.50	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	277	0	1	04	01	H5521_277_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											45.57	25	25	25				53.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	277	0	1	04	01	H5521_277_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											573.66	25						731.36	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	25			25			25			25			25		25
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											69.12	24	24	24				96.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											527.78	25						592.66	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	25			25			25			25			25		25
H5521	289	0	1	04	01	H5521_289_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.41	24	24	24				95.02	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	289	0	1	04	01	H5521_289_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.07	25	25	25				44.05	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	289	0	1	04	01	H5521_289_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											617.41	25						790.39	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	25			25			25			25			25		25
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											66.46	24	24	24				93.23	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.13	25	25	25				45.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											553.63	25						645.67	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	25			25			25			25			25		25
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											69.95	24	24	24				96.96	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											607.98	25						574.40	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	25			25			25			25			25		25
H5521	302	0	1	04	01	H5521_302_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.11	22	22	22				84.63	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	302	0	1	04	01	H5521_302_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.27	25	25	25				46.68	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	302	0	1	04	01	H5521_302_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											532.80	25						580.04	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	25			25			25			25			25		25
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											70.29	24	24	24				97.69	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.49	25	25	25				46.44	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											492.70	25						685.04	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	25			25			25			25			25		25
H5521	305	0	1	04	01	H5521_305_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.96	24	24	24				89.71	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	305	0	1	04	01	H5521_305_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.47	25	25	25				42.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	305	0	1	04	01	H5521_305_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											540.90	25						601.53	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											71.00	24	24	24				97.68	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.93	25	25	25				43.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											484.45	25						640.07	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											63.15	22	22	22				85.11	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											39.86	25	25	25				39.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											560.48	27						620.53	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	25			25			25			25			25		25
H5521	326	0	1	04	01	H5521_326_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	326	0	1	04	01	H5521_326_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.39	22	22	22				85.90	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	326	0	1	04	01	H5521_326_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											43.91	25	25	25				44.93	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	326	0	1	04	01	H5521_326_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											528.52	25						560.46	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	25			25			25			25			25		25
H5521	340	0	1	04	01	H5521_340_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	340	0	1	04	01	H5521_340_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	340	0	1	04	01	H5521_340_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											77.78	24	24	24				98.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	340	0	1	04	01	H5521_340_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											41.72	25	25	25				50.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	340	0	1	04	01	H5521_340_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											563.86	25						599.32	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	25			25			25			25			25		25
H5521	348	0	1	04	01	H5521_348_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.73	24	24	24				94.22	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	348	0	1	04	01	H5521_348_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	348	0	1	04	01	H5521_348_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											555.37	25						698.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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											74.43	24	24	24				100.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											45.00	25	25	25				49.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											549.96	25						606.31	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	25			25			25			25			25		25
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											68.58	24	24	24				95.24	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.07	25	25	25				45.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.05	25						742.02	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	25			25			25			25			25		25
H5521	364	0	1	04	01	H5521_364_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.06	22	22	22				91.13	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	364	0	1	04	01	H5521_364_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.50	25	25	25				49.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	364	0	1	04	01	H5521_364_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											595.21	25						604.01	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	25			25			25			25			25		25
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											68.31	24	24	24				90.83	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.45	25	25	25				42.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											551.05	25						624.63	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	25			25			25			25			25		25
H5521	375	0	1	04	01	H5521_375_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	375	0	1	04	01	H5521_375_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											73.74	24	24	24				98.05	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	375	0	1	04	01	H5521_375_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	375	0	1	04	01	H5521_375_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.61	25						577.43	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	25			25			25			25			25		25
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											73.60	22	22	22				92.26	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											45.72	25	25	25				53.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											624.16	27						678.67	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	25			25			25			25			25		25
H5521	388	0	1	04	01	H5521_388_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	388	0	1	04	01	H5521_388_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.68	24	24	24				91.94	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	388	0	1	04	01	H5521_388_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.30	25	25	25				45.47	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	388	0	1	04	01	H5521_388_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											588.33	25						725.76	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	25			25			25			25			25		25
H5521	392	0	1	04	01	H5521_392_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	392	0	1	04	01	H5521_392_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	392	0	1	04	01	H5521_392_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.30	24	24	24				98.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	392	0	1	04	01	H5521_392_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											45.32	25	25	25				45.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	392	0	1	04	01	H5521_392_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											620.92	25						723.37	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											65.10	24	24	24				90.84	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.19	25	25	25				43.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											502.41	25						581.80	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	25			25			25			25			25		25
H5521	398	0	1	04	01	H5521_398_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	398	0	1	04	01	H5521_398_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	398	0	1	04	01	H5521_398_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.09	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	22	22	22				22	22	22				22		22
H5521	398	0	1	04	01	H5521_398_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.51	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5521	398	0	1	04	01	H5521_398_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				488.61	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5521	399	0	1	04	01	H5521_399_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.61	22	22	22				80.98	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	399	0	1	04	01	H5521_399_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.06	25	25	25				49.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	399	0	1	04	01	H5521_399_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											464.94	25						593.88	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	25			25			25			25			25		25
H5521	400	0	1	04	01	H5521_400_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.88	22	22	22				82.13	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	400	0	1	04	01	H5521_400_0	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				48.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	400	0	1	04	01	H5521_400_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											555.83	25						640.89	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	25			25			25			25			25		25
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											72.34	24	24	24				88.68	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.47	25	25	25				40.45	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											578.38	25						612.35	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	25			25			25			25			25		25
H5521	404	0	1	04	01	H5521_404_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	404	0	1	04	01	H5521_404_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	404	0	1	04	01	H5521_404_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.67	24	24	24				91.98	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	404	0	1	04	01	H5521_404_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											37.18	25	25	25				45.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	404	0	1	04	01	H5521_404_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											512.34	25						606.43	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	25			25			25			25			25		25
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											66.67	24	24	24				90.29	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.16	25	25	25				45.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											544.71	25						665.26	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	25			25			25			25			25		25
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											69.34	24	24	24				89.63	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.47	25	25	25				46.13	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											501.13	25						616.12	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	25			25			25			25			25		25
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											64.90	22	22	22				88.96	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											40.77	25	25	25				51.71	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											581.26	25						624.14	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	25			25			25			25			25		25
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											66.28	24	24	24				91.46	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.99	25	25	25				46.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											542.65	25						512.02	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	25			25			25			25			25		25
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											63.32	24	24	24				88.54	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.86	25	25	25				46.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											495.44	25						584.48	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	25			25			25			25			25		25
H5521	425	0	1	04	01	H5521_425_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.65	24	24	24				92.89	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	425	0	1	04	01	H5521_425_0	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				47.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	425	0	1	04	01	H5521_425_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											556.95	25						627.19	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	25			25			25			25			25		25
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											60.14	24	24	24				89.94	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.49	25	25	25				43.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											551.61	25						691.21	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	25			25			25			25			25		25
H5521	432	0	1	04	01	H5521_432_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			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				97.18	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	432	0	1	04	01	H5521_432_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.10	25	25	25				44.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	432	0	1	04	01	H5521_432_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											561.71	25						527.40	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	25			25			25			25			25		25
H5521	433	0	1	04	01	H5521_433_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.70	24	24	24				89.19	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	433	0	1	04	01	H5521_433_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											37.57	25	25	25				43.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	433	0	1	04	01	H5521_433_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											514.72	25						599.37	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	25			25			25			25			25		25
H5521	434	0	1	04	01	H5521_434_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											62.82	24	24	24				93.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	434	0	1	04	01	H5521_434_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.24	25	25	25				41.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	434	0	1	04	01	H5521_434_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											491.72	25						562.40	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	25			25			25			25			25		25
H5521	435	0	1	04	01	H5521_435_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.48	24	24	24				91.24	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	435	0	1	04	01	H5521_435_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.66	25	25	25				42.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	435	0	1	04	01	H5521_435_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											532.39	25						608.99	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	25			25			25			25			25		25
H5521	439	0	1	04	01	H5521_439_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											66.67	24	24	24				94.15	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	439	0	1	04	01	H5521_439_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.95	25	25	25				42.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	439	0	1	04	01	H5521_439_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											511.53	25						565.35	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	25			25			25			25			25		25
H5521	443	0	1	04	01	H5521_443_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.01	22	22	22				88.73	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	443	0	1	04	01	H5521_443_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.53	25	25	25				52.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	443	0	1	04	01	H5521_443_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											612.18	25						632.61	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	25			25			25			25			25		25
H5521	446	0	1	04	01	H5521_446_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.48	24	24	24				93.62	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	446	0	1	04	01	H5521_446_0	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	25	25	25				46.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	446	0	1	04	01	H5521_446_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											518.73	25						634.73	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	25			25			25			25			25		25
H5521	449	0	1	04	01	H5521_449_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.63	22	22	22				83.94	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	449	0	1	04	01	H5521_449_0	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				45.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	449	0	1	04	01	H5521_449_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											527.88	25						583.91	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											70.88	22	22	22				86.12	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											38.08	25	25	25				42.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											627.42	27						603.01	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											74.82	24	24	24				90.36	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.92	25	25	25				44.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											551.84	25						545.18	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	25			25			25			25			25		25
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											81.05	24	24	24				104.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.28	25	25	25				51.09	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											565.07	25						684.88	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	25			25			25			25			25		25
H5521	464	0	1	04	01	H5521_464_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	464	0	1	04	01	H5521_464_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	464	0	1	04	01	H5521_464_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				64.77	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	22	22	22				22	22	22				22		22
H5521	464	0	1	04	01	H5521_464_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				34.41	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5521	464	0	1	04	01	H5521_464_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				462.82	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5521	465	0	1	04	01	H5521_465_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	465	0	1	04	01	H5521_465_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	465	0	1	04	01	H5521_465_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				68.21	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	22	22	22				22	22	22				22		22
H5521	465	0	1	04	01	H5521_465_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				35.45	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	25	25	25				25	25	25				25		25
H5521	465	0	1	04	01	H5521_465_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				470.24	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	467	0	1	04	01	H5521_467_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.20	22	22	22				83.69	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	467	0	1	04	01	H5521_467_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											39.11	25	25	25				47.46	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											563.20	25						636.26	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	25			25			25			25			25		25
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											65.90	22	22	22				83.23	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											37.73	25	25	25				47.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											532.67	25						579.43	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	25			25			25			25			25		25
H5521	472	0	1	04	01	H5521_472_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	472	0	1	04	01	H5521_472_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5521	472	0	1	04	01	H5521_472_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				68.89	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	22	22	22				22	22	22				22		22
H5521	472	0	1	04	01	H5521_472_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				37.39	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5521	472	0	1	04	01	H5521_472_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				479.94	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5521	475	0	1	04	01	H5521_475_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.66	24	24	24				91.73	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	475	0	1	04	01	H5521_475_0	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				44.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	475	0	1	04	01	H5521_475_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											566.81	25						680.51	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	25			25			25			25			25		25
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											68.64	24	24	24				88.69	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.88	25	25	25				43.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											548.07	25						696.95	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	25			25			25			25			25		25
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											64.78	24	24	24				88.51	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.96	25	25	25				44.72	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											553.78	25						698.25	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	25			25			25			25			25		25
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											62.45	24	24	24				89.99	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.11	25	25	25				45.66	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											536.85	25						651.32	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	25			25			25			25			25		25
H5521	482	0	1	04	01	H5521_482_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											70.29	24	24	24				95.94	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	482	0	1	04	01	H5521_482_0	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	25	25	25				50.12	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	482	0	1	04	01	H5521_482_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											600.45	25						703.28	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											64.73	24	24	24				91.22	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.55	25	25	25				48.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											545.16	25						662.52	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	25			25			25			25			25		25
H5521	490	0	1	04	01	H5521_490_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	490	0	1	04	01	H5521_490_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.64	22	22	22				80.37	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	490	0	1	04	01	H5521_490_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.35	25	25	25				51.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	490	0	1	04	01	H5521_490_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											507.24	25						589.98	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	25			25			25			25			25		25
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											67.65	24	24	24				96.03	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.94	25	25	25				49.23	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											596.41	25						769.42	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											62.61	22	22	22				88.07	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
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											42.90	25	25	25				47.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											655.44	27						834.09	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	25			25			25			25			25		25
H5521	496	0	1	04	01	H5521_496_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.20	22	22	22				79.71	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	496	0	1	04	01	H5521_496_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											38.95	25	25	25				48.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	496	0	1	04	01	H5521_496_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											507.44	25						604.18	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	25			25			25			25			25		25
H5521	500	0	1	04	01	H5521_500_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	500	0	1	04	01	H5521_500_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.73	24	24	24				89.80	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	500	0	1	04	01	H5521_500_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											44.76	25	25	25				46.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	500	0	1	04	01	H5521_500_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											580.54	25						759.23	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	25			25			25			25			25		25
H5521	501	0	1	04	01	H5521_501_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	501	0	1	04	01	H5521_501_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											57.18	22	22	22				79.67	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	501	0	1	04	01	H5521_501_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.31	25	25	25				48.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	501	0	1	04	01	H5521_501_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											548.01	25						691.63	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											58.77	24	24	24				84.18	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.49	25	25	25				47.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											497.24	25						724.69	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	25			25			25			25			25		25
H5521	510	0	1	04	01	H5521_510_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	510	0	1	04	01	H5521_510_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	510	0	1	04	01	H5521_510_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.17	24	24	24				99.07	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	510	0	1	04	01	H5521_510_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											45.35	25	25	25				49.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	510	0	1	04	01	H5521_510_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											644.06	25						762.50	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	25			25			25			25			25		25
H5521	512	0	1	04	01	H5521_512_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	512	0	1	04	01	H5521_512_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	512	0	1	04	01	H5521_512_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.17	22	22	22				87.10	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	512	0	1	04	01	H5521_512_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											49.90	25	25	25				50.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	512	0	1	04	01	H5521_512_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											686.25	27						797.91	27												27						27						27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5521	513	0	1	04	01	H5521_513_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	513	0	1	04	01	H5521_513_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	513	0	1	04	01	H5521_513_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	24	24	24				99.70	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	513	0	1	04	01	H5521_513_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				54.68	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	513	0	1	04	01	H5521_513_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											536.01	25						841.41	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	25			25			25			25			25		25
H5521	520	0	1	04	01	H5521_520_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	520	0	1	04	01	H5521_520_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	520	0	1	04	01	H5521_520_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											72.00	24	24	24				101.18	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	520	0	1	04	01	H5521_520_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											45.52	25	25	25				49.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	520	0	1	04	01	H5521_520_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											607.07	25						844.88	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	25			25			25			25			25		25
H5521	521	0	1	04	01	H5521_521_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	521	0	1	04	01	H5521_521_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	521	0	1	04	01	H5521_521_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											74.43	24	24	24				101.30	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	521	0	1	04	01	H5521_521_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											44.24	25	25	25				52.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	521	0	1	04	01	H5521_521_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											649.38	25						989.13	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	25			25			25			25			25		25
H5521	522	0	1	04	01	H5521_522_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	522	0	1	04	01	H5521_522_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	522	0	1	04	01	H5521_522_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											61.04	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	522	0	1	04	01	H5521_522_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				49.36	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	522	0	1	04	01	H5521_522_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											548.16	25						640.78	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	25			25			25			25			25		25
H5521	536	0	1	04	01	H5521_536_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	536	0	1	04	01	H5521_536_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	536	0	1	04	01	H5521_536_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											85.87	24	24	24				105.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	536	0	1	04	01	H5521_536_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											52.58	25	25	25				56.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	536	0	1	04	01	H5521_536_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											563.81	25						805.14	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	25			25			25			25			25		25
H5521	537	0	1	04	01	H5521_537_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	537	0	1	04	01	H5521_537_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	537	0	1	04	01	H5521_537_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.01	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	537	0	1	04	01	H5521_537_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											53.99	25	25	25				55.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	537	0	1	04	01	H5521_537_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											639.43	25						612.88	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	25			25			25			25			25		25
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											65.42	24	24	24				83.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											35.19	25	25	25				43.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											495.54	25						690.33	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	25			25			25			25			25		25
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											63.38	24	24	24				95.13	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.59	25	25	25				51.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											585.33	25						692.71	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	25			25			25			25			25		25
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											60.45	24	24	24				93.73	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.05	25	25	25				44.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											422.53	25						839.22	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	25			25			25			25			25		25
H5521	569	0	1	04	01	H5521_569_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.42	24	24	24				92.46	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	569	0	1	04	01	H5521_569_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.55	25	25	25				44.95	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	569	0	1	04	01	H5521_569_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											609.99	25						687.19	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	25			25			25			25			25		25
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											64.26	24	24	24				91.75	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.80	25	25	25				50.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											578.61	25						705.61	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	25			25			25			25			25		25
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											65.10	24	24	24				90.54	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.85	25	25	25				47.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											590.67	25						718.93	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	25			25			25			25			25		25
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											64.48	24	24	24				94.54	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											40.34	25	25	25				48.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											566.55	25						673.43	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	25			25			25			25			25		25
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											58.84	24	24	24				87.74	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.88	25	25	25				43.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											563.73	25						689.37	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	25			25			25			25			25		25
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											77.87	24	24	24				98.17	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											54.91	25	25	25				52.04	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											653.27	25						601.05	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	25			25			25			25			25		25
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											62.76	24	24	24				90.44	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											39.73	25	25	25				46.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											534.48	25						658.31	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	25			25			25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											66.72	24	24	24				88.52	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.51	25	25	25				51.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											622.83	25						627.19	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	25			25			25			25			25		25
H5521	644	0	1	04	01	H5521_644_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.68	24	24	24				90.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	644	0	1	04	01	H5521_644_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.77	25	25	25				47.75	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	644	0	1	04	01	H5521_644_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											549.90	25						669.58	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	25			25			25			25			25		25
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											66.01	24	24	24				89.37	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.24	25	25	25				49.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											533.80	25						740.16	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	25			25			25			25			25		25
H5521	646	0	1	04	01	H5521_646_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	646	0	1	04	01	H5521_646_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	646	0	1	04	01	H5521_646_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											58.57	22	22	22				79.09	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	646	0	1	04	01	H5521_646_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											38.80	25	25	25				48.10	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	646	0	1	04	01	H5521_646_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											515.74	25						612.04	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	25			25			25			25			25		25
H5521	649	0	1	04	01	H5521_649_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	649	0	1	04	01	H5521_649_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	649	0	1	04	01	H5521_649_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.33	22	22	22				88.93	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	649	0	1	04	01	H5521_649_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											42.05	25	25	25				50.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	649	0	1	04	01	H5521_649_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											591.22	25						715.63	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	25			25			25			25			25		25
H5521	650	0	1	04	01	H5521_650_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	650	0	1	04	01	H5521_650_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	650	0	1	04	01	H5521_650_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.23	24	24	24				90.21	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	650	0	1	04	01	H5521_650_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.00	25	25	25				47.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	650	0	1	04	01	H5521_650_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.73	25						658.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5521	652	0	1	04	01	H5521_652_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	652	0	1	04	01	H5521_652_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	652	0	1	04	01	H5521_652_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											64.23	24	24	24				90.21	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	652	0	1	04	01	H5521_652_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.00	25	25	25				47.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	652	0	1	04	01	H5521_652_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.73	25						658.94	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5521	654	0	1	04	01	H5521_654_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	654	0	1	04	01	H5521_654_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	654	0	1	04	01	H5521_654_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.22	24	24	24				94.69	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	654	0	1	04	01	H5521_654_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.65	25	25	25				48.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	654	0	1	04	01	H5521_654_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											578.24	25						723.34	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	25			25			25			25			25		25
H5521	656	0	1	04	01	H5521_656_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	656	0	1	04	01	H5521_656_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	656	0	1	04	01	H5521_656_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.51	24	24	24				94.78	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	656	0	1	04	01	H5521_656_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.70	25	25	25				48.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	656	0	1	04	01	H5521_656_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											578.14	25						720.20	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	25			25			25			25			25		25
H5521	661	0	1	04	01	H5521_661_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	661	0	1	04	01	H5521_661_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	661	0	1	04	01	H5521_661_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.17	24	24	24				103.57	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	661	0	1	04	01	H5521_661_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											55.61	25	25	25				54.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	661	0	1	04	01	H5521_661_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.21	25						605.43	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	25			25			25			25			25		25
H5521	662	0	1	04	01	H5521_662_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	662	0	1	04	01	H5521_662_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	662	0	1	04	01	H5521_662_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.15	24	24	24				103.57	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	662	0	1	04	01	H5521_662_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											55.60	25	25	25				54.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	662	0	1	04	01	H5521_662_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.27	25						605.59	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	25			25			25			25			25		25
H5521	664	0	1	04	01	H5521_664_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	664	0	1	04	01	H5521_664_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	664	0	1	04	01	H5521_664_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.56	24	24	24				103.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	664	0	1	04	01	H5521_664_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											55.41	25	25	25				53.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	664	0	1	04	01	H5521_664_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											524.73	25						617.35	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	25			25			25			25			25		25
H5521	665	0	1	04	01	H5521_665_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	665	0	1	04	01	H5521_665_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	665	0	1	04	01	H5521_665_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.58	24	24	24				103.82	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	665	0	1	04	01	H5521_665_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											55.42	25	25	25				53.06	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	665	0	1	04	01	H5521_665_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											524.65	25						617.14	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	25			25			25			25			25		25
H5521	669	0	1	04	01	H5521_669_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	669	0	1	04	01	H5521_669_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	669	0	1	04	01	H5521_669_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											76.72	24	24	24				99.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	669	0	1	04	01	H5521_669_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											43.09	25	25	25				49.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	669	0	1	04	01	H5521_669_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											558.96	25						629.18	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	25			25			25			25			25		25
H5521	674	0	1	04	01	H5521_674_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	674	0	1	04	01	H5521_674_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	674	0	1	04	01	H5521_674_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.53	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	674	0	1	04	01	H5521_674_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											55.45	25	25	25				53.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	674	0	1	04	01	H5521_674_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											525.78	25						615.35	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	25			25			25			25			25		25
H5521	676	0	1	04	01	H5521_676_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	676	0	1	04	01	H5521_676_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	676	0	1	04	01	H5521_676_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											63.74	24	24	24				91.47	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	676	0	1	04	01	H5521_676_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.27	25	25	25				48.28	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	676	0	1	04	01	H5521_676_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											538.59	25						634.98	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	25			25			25			25			25		25
H5521	685	0	1	04	01	H5521_685_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	685	0	1	04	01	H5521_685_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	685	0	1	04	01	H5521_685_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.12	24	24	24				94.58	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	685	0	1	04	01	H5521_685_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.82	25	25	25				48.98	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	685	0	1	04	01	H5521_685_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											573.95	25						690.62	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	25			25			25			25			25		25
H5521	686	0	1	04	01	H5521_686_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	686	0	1	04	01	H5521_686_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	686	0	1	04	01	H5521_686_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.98	22	22	22				86.07	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	686	0	1	04	01	H5521_686_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.95	25	25	25				46.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	686	0	1	04	01	H5521_686_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											623.68	27						785.06	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	25			25			25			25			25		25
H5521	687	0	1	04	01	H5521_687_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	687	0	1	04	01	H5521_687_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	687	0	1	04	01	H5521_687_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											59.98	22	22	22				86.07	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5521	687	0	1	04	01	H5521_687_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.95	25	25	25				46.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	687	0	1	04	01	H5521_687_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											623.68	27						785.06	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	25			25			25			25			25		25
H5521	688	0	1	04	01	H5521_688_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	688	0	1	04	01	H5521_688_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	688	0	1	04	01	H5521_688_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.24	24	24	24				94.73	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	688	0	1	04	01	H5521_688_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.79	25	25	25				45.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	688	0	1	04	01	H5521_688_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											541.86	25						546.65	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	25			25			25			25			25		25
H5521	698	0	1	04	01	H5521_698_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	698	0	1	04	01	H5521_698_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	698	0	1	04	01	H5521_698_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.53	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	698	0	1	04	01	H5521_698_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											55.45	25	25	25				53.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	698	0	1	04	01	H5521_698_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											525.79	25						615.36	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	25			25			25			25			25		25
H5521	699	0	1	04	01	H5521_699_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	699	0	1	04	01	H5521_699_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	699	0	1	04	01	H5521_699_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											93.52	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	699	0	1	04	01	H5521_699_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											55.45	25	25	25				53.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	699	0	1	04	01	H5521_699_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											525.82	25						615.44	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	25			25			25			25			25		25
H5521	702	0	1	04	01	H5521_702_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	702	0	1	04	01	H5521_702_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	702	0	1	04	01	H5521_702_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											71.64	24	24	24				95.54	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	702	0	1	04	01	H5521_702_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											49.60	25	25	25				42.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	702	0	1	04	01	H5521_702_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											562.20	25						581.45	25												25						25						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5521	704	0	1	04	01	H5521_704_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	704	0	1	04	01	H5521_704_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	704	0	1	04	01	H5521_704_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.26	24	24	24				94.74	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	704	0	1	04	01	H5521_704_0	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				45.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	704	0	1	04	01	H5521_704_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											541.89	25						546.41	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	25			25			25			25			25		25
H5521	705	0	1	04	01	H5521_705_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	705	0	1	04	01	H5521_705_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	705	0	1	04	01	H5521_705_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.57	24	24	24				94.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	705	0	1	04	01	H5521_705_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											47.15	25	25	25				45.85	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	705	0	1	04	01	H5521_705_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											540.23	25						555.12	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	25			25			25			25			25		25
H5521	706	0	1	04	01	H5521_706_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	706	0	1	04	01	H5521_706_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	706	0	1	04	01	H5521_706_0	3			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.55	24	24	24				94.44	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	706	0	1	04	01	H5521_706_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											47.13	25	25	25				45.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	706	0	1	04	01	H5521_706_0	3			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											540.20	25						555.33	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	25			25			25			25			25		25
H5521	710	0	1	04	01	H5521_710_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	710	0	1	04	01	H5521_710_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	710	0	1	04	01	H5521_710_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											67.30	24	24	24				94.31	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5521	710	0	1	04	01	H5521_710_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											46.94	25	25	25				45.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5521	710	0	1	04	01	H5521_710_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											540.29	25						556.81	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	25			25			25			25			25		25
H5522	001	0	1	04	01	H5522_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																														
H5522	001	0	1	04	01	H5522_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																														
H5522	001	0	1	04	01	H5522_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											58.96	22	22	22				87.99	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5522	001	0	1	04	01	H5522_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											39.65	25	25	25				49.14	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	001	0	1	04	01	H5522_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											491.74	25						587.30	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	25			25			25			25			25		25
H5522	002	0	1	04	01	H5522_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																														
H5522	002	0	1	04	01	H5522_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																														
H5522	002	0	1	04	01	H5522_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											65.03	24	24	24				90.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5522	002	0	1	04	01	H5522_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											42.88	25	25	25				46.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	002	0	1	04	01	H5522_002_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											377.75	25						531.09	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	25			25			25			25			25		25
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											64.21	24	24	24				95.18	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.94	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											488.48	25						529.31	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	25			25			25			25			25		25
H5522	005	0	1	04	01	H5522_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																														
H5522	005	0	1	04	01	H5522_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																														
H5522	005	0	1	04	01	H5522_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											61.97	22	22	22				86.15	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5522	005	0	1	04	01	H5522_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											36.66	25	25	25				46.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	005	0	1	04	01	H5522_005_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											492.30	25						512.96	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	25			25			25			25			25		25
H5522	013	0	1	04	01	H5522_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																														
H5522	013	0	1	04	01	H5522_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																														
H5522	013	0	1	04	01	H5522_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											64.97	22	22	22				87.70	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5522	013	0	1	04	01	H5522_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											36.66	25	25	25				46.60	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	013	0	1	04	01	H5522_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											474.08	25						586.74	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	25			25			25			25			25		25
H5522	014	0	1	04	01	H5522_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																														
H5522	014	0	1	04	01	H5522_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																														
H5522	014	0	1	04	01	H5522_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											64.02	24	24	24				92.45	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5522	014	0	1	04	01	H5522_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											44.88	25	25	25				46.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	014	0	1	04	01	H5522_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											524.51	25						512.97	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	25			25			25			25			25		25
H5522	017	0	1	04	01	H5522_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																														
H5522	017	0	1	04	01	H5522_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																														
H5522	017	0	1	04	01	H5522_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											63.90	24	24	24				95.44	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5522	017	0	1	04	01	H5522_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											38.69	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	017	0	1	04	01	H5522_017_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.94	25						675.64	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	25			25			25			25			25		25
H5522	022	0	1	04	01	H5522_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																														
H5522	022	0	1	04	01	H5522_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																														
H5522	022	0	1	04	01	H5522_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											69.98	24	24	24				99.10	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5522	022	0	1	04	01	H5522_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											37.66	25	25	25				45.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	022	0	1	04	01	H5522_022_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											501.85	25						591.86	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	25			25			25			25			25		25
H5522	028	0	1	04	01	H5522_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																														
H5522	028	0	1	04	01	H5522_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																														
H5522	028	0	1	04	01	H5522_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											64.63	24	24	24				90.93	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5522	028	0	1	04	01	H5522_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											38.66	25	25	25				43.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5522	028	0	1	04	01	H5522_028_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											537.60	25						607.96	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	25			25			25			25			25		25
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											68.21	24	24	24				93.61	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.37	25	25	25				43.44	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											503.27	25						580.25	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	25			25			25			25			25		25
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											66.79	24	24	24				97.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											41.71	25	25	25				49.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											565.00	25						691.15	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	25			25			25			25			25		25
H5525	004	0	1	04	01	H5525_004_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	0		0				25		25	0		0	0		0
H5525	004	0	1	04	01	H5525_004_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	004	0	1	04	01	H5525_004_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	25		25				25		25	25		25	25		25
H5525	004	0	1	04	01	H5525_004_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	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5525	005	0	1	04	01	H5525_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	0		0				25		25	0		0	0		0
H5525	005	0	1	04	01	H5525_005_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	005	0	1	04	01	H5525_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	25		25				25		25	25		25	25		25
H5525	005	0	1	04	01	H5525_005_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	25		25				25		25	25		25	25		25
H5525	005	0	1	04	01	H5525_005_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	25						25			25			25		25
H5525	006	0	1	04	01	H5525_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	0		0				25		25	0		0	0		0
H5525	006	0	1	04	01	H5525_006_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	006	0	1	04	01	H5525_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	25		25				25		25	25		25	25		25
H5525	006	0	1	04	01	H5525_006_0	3			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	25		25				25		25	25		25	25		25
H5525	006	0	1	04	01	H5525_006_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	25						25			25			25		25
H5525	008	0	1	04	01	H5525_008_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	0		0				25		25	0		0	0		0
H5525	008	0	1	04	01	H5525_008_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	008	0	1	04	01	H5525_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	25		25				25		25	25		25	25		25
H5525	008	0	1	04	01	H5525_008_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	008	0	1	04	01	H5525_008_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	25						25			25			25		25
H5525	030	0	1	04	01	H5525_030_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	0		0				25		25	0		0	0		0
H5525	030	0	1	04	01	H5525_030_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	25		25				25		25	25		0	25		25
H5525	030	0	1	04	01	H5525_030_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	25		25				25		25	25		25	25		25
H5525	030	0	1	04	01	H5525_030_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H5525	030	0	1	04	01	H5525_030_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	25						25			25			25		25
H5525	034	0	1	04	01	H5525_034_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	0		0				25		25	0		0	0		0
H5525	034	0	1	04	01	H5525_034_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	034	0	1	04	01	H5525_034_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	25		25				25		25	25		25	25		25
H5525	034	0	1	04	01	H5525_034_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	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	25		25				25		25	25		25	25		25
H5525	034	0	1	04	01	H5525_034_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	25						25			25			25		25
H5525	035	0	1	04	01	H5525_035_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	0		0				25		25	0		0	0		0
H5525	035	0	1	04	01	H5525_035_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	035	0	1	04	01	H5525_035_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	25		25				25		25	25		25	25		25
H5525	035	0	1	04	01	H5525_035_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	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	25		25				25		25	25		25	25		25
H5525	035	0	1	04	01	H5525_035_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	25						25			25			25		25
H5525	036	0	1	04	01	H5525_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	0		0				25		25	0		0	0		0
H5525	036	0	1	04	01	H5525_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	0		0				25		25	0		0	0		0
H5525	036	0	1	04	01	H5525_036_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	036	0	1	04	01	H5525_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				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	25		25				25		25	25		25	25		25
H5525	036	0	1	04	01	H5525_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	25						25			25			25		25
H5525	041	0	1	04	01	H5525_041_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	0		0				25		25	0		0	0		0
H5525	041	0	1	04	01	H5525_041_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	041	0	1	04	01	H5525_041_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	25		25				25		25	25		25	25		25
H5525	041	0	1	04	01	H5525_041_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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	25		25				25		25	25		25	25		25
H5525	041	0	1	04	01	H5525_041_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	25						25			25			25		25
H5525	042	0	1	04	01	H5525_042_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	0		0				25		25	0		0	0		0
H5525	042	0	1	04	01	H5525_042_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	042	0	1	04	01	H5525_042_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	25		25				25		25	25		25	25		25
H5525	042	0	1	04	01	H5525_042_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	25		25				25		25	25		25	25		25
H5525	042	0	1	04	01	H5525_042_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	25						25			25			25		25
H5525	045	0	1	04	01	H5525_045_0	3		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	0		0				25		25	0		0	0		0
H5525	045	0	1	04	01	H5525_045_0	3		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	0		0				25		25	0		0	0		0
H5525	045	0	1	04	01	H5525_045_0	3		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	045	0	1	04	01	H5525_045_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	045	0	1	04	01	H5525_045_0	3		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	25						25			25			25		25
H5525	046	0	1	04	01	H5525_046_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	0		0				25		25	0		0	0		0
H5525	046	0	1	04	01	H5525_046_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	0		0				25		25	0		0	0		0
H5525	046	0	1	04	01	H5525_046_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	046	0	1	04	01	H5525_046_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5525	046	0	1	04	01	H5525_046_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	25						25			25			25		25
H5525	049	0	1	04	01	H5525_049_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	0		0				25		25	0		0	0		0
H5525	049	0	1	04	01	H5525_049_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	049	0	1	04	01	H5525_049_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	25		25				25		25	25		25	25		25
H5525	049	0	1	04	01	H5525_049_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	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	25		25				25		25	25		25	25		25
H5525	049	0	1	04	01	H5525_049_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	25						25			25			25		25
H5525	050	0	1	04	01	H5525_050_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	0		0				25		25	0		0	0		0
H5525	050	0	1	04	01	H5525_050_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	050	0	1	04	01	H5525_050_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	25		25				25		25	25		25	25		25
H5525	050	0	1	04	01	H5525_050_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	25		25				25		25	25		25	25		25
H5525	050	0	1	04	01	H5525_050_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	25						25			25			25		25
H5525	051	1	1	04	01	H5525_051_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	0		0				25		25	0		0	0		0
H5525	051	1	1	04	01	H5525_051_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	051	1	1	04	01	H5525_051_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	25		25				25		25	25		25	25		25
H5525	051	1	1	04	01	H5525_051_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H5525	051	1	1	04	01	H5525_051_1	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	25						25			25			25		25
H5525	051	2	1	04	01	H5525_051_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	0		0				25		25	0		0	0		0
H5525	051	2	1	04	01	H5525_051_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	051	2	1	04	01	H5525_051_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	25		25				25		25	25		25	25		25
H5525	051	2	1	04	01	H5525_051_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H5525	051	2	1	04	01	H5525_051_2	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	25						25			25			25		25
H5525	054	0	1	04	01	H5525_054_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	0		0				25		25	0		0	0		0
H5525	054	0	1	04	01	H5525_054_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	054	0	1	04	01	H5525_054_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	25		25				25		25	25		25	25		25
H5525	054	0	1	04	01	H5525_054_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5525	054	0	1	04	01	H5525_054_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	25						25			25			25		25
H5525	056	0	1	04	01	H5525_056_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	0		0				25		25	0		0	0		0
H5525	056	0	1	04	01	H5525_056_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	056	0	1	04	01	H5525_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	25		25				25		25	25		25	25		25
H5525	056	0	1	04	01	H5525_056_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	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	25		25				25		25	25		25	25		25
H5525	056	0	1	04	01	H5525_056_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	25						25			25			25		25
H5525	057	0	1	04	01	H5525_057_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	0		0				25		25	0		0	0		0
H5525	057	0	1	04	01	H5525_057_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	057	0	1	04	01	H5525_057_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	25		25				25		25	25		25	25		25
H5525	057	0	1	04	01	H5525_057_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	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	25		25				25		25	25		25	25		25
H5525	057	0	1	04	01	H5525_057_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	25						25			25			25		25
H5525	059	0	1	04	01	H5525_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	0		0				25		25	0		0	0		0
H5525	059	0	1	04	01	H5525_059_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5525	059	0	1	04	01	H5525_059_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	31.00		93.00																									47.00		141.00				31.00		62.00				31.00				31.00		1.03				1.57	1.03	1.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	31.00		93.00				35.00		105.00	31.00		62.00	31.00		31.00	25		25				25		25	25		25	25		25
H5525	059	0	1	04	01	H5525_059_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				74.00	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	25		25				25		25	25		25	25		25
H5525	059	0	1	04	01	H5525_059_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	25						25			25			25		25
H5525	070	0	1	04	01	H5525_070_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	0.00		0.00				1.00		3.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5525	070	0	1	04	01	H5525_070_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	070	0	1	04	01	H5525_070_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	25		25				25		25	25		25	25		25
H5525	070	0	1	04	01	H5525_070_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	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	25		25				25		25	25		25	25		25
H5525	070	0	1	04	01	H5525_070_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	25						25			25			25		25
H5525	072	0	1	04	01	H5525_072_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	0		0				25		25	0		0	0		0
H5525	072	0	1	04	01	H5525_072_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	0		0				25		25	0		0	0		0
H5525	072	0	1	04	01	H5525_072_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5525	072	0	1	04	01	H5525_072_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5525	072	0	1	04	01	H5525_072_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	25						25			25			25		25
H5525	074	0	1	04	01	H5525_074_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	0		0				25		25	0		0	0		0
H5525	074	0	1	04	01	H5525_074_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00	25		25				25		25	25		0	25		25
H5525	074	0	1	04	01	H5525_074_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	25		25				25		25	25		25	25		25
H5525	074	0	1	04	01	H5525_074_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	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	25		25				25		25	25		25	25		25
H5525	074	0	1	04	01	H5525_074_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	25						25			25			25		25
H5525	075	0	1	04	01	H5525_075_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	0		0				25		25	0		0	0		0
H5525	075	0	1	04	01	H5525_075_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	075	0	1	04	01	H5525_075_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	25		25				25		25	25		25	25		25
H5525	075	0	1	04	01	H5525_075_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	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	25		25				25		25	25		25	25		25
H5525	075	0	1	04	01	H5525_075_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	25						25			25			25		25
H5525	077	0	1	04	01	H5525_077_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	0		0				25		25	0		0	0		0
H5525	077	0	1	04	01	H5525_077_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	077	0	1	04	01	H5525_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		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	25		25				25		25	25		25	25		25
H5525	077	0	1	04	01	H5525_077_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	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	25		25				25		25	25		25	25		25
H5525	077	0	1	04	01	H5525_077_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	25						25			25			25		25
H5525	080	0	1	04	01	H5525_080_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	0		0				25		25	0		0	0		0
H5525	080	0	1	04	01	H5525_080_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	25		25				25		25	25		0	25		25
H5525	080	0	1	04	01	H5525_080_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	25		25				25		25	25		25	25		25
H5525	080	0	1	04	01	H5525_080_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	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	25		25				25		25	25		25	25		25
H5525	080	0	1	04	01	H5525_080_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	25						25			25			25		25
H5525	083	0	1	04	01	H5525_083_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	0		0				25		25	0		0	0		0
H5525	083	0	1	04	01	H5525_083_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	0		0				25		25	0		0	0		0
H5525	083	0	1	04	01	H5525_083_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	25		25				25		25	25		25	25		25
H5525	083	0	1	04	01	H5525_083_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	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	25		25				25		25	25		25	25		25
H5525	083	0	1	04	01	H5525_083_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	25						25			25			25		25
H5525	084	0	1	04	01	H5525_084_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	0		0				25		25	0		0	0		0
H5525	084	0	1	04	01	H5525_084_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	084	0	1	04	01	H5525_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		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	25		25				25		25	25		25	25		25
H5525	084	0	1	04	01	H5525_084_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	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	25		25				25		25	25		25	25		25
H5525	084	0	1	04	01	H5525_084_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	25						25			25			25		25
H5525	085	1	1	04	01	H5525_085_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	0		0				25		25	0		0	0		0
H5525	085	1	1	04	01	H5525_085_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	0		0				25		25	0		0	0		0
H5525	085	1	1	04	01	H5525_085_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	25		25				25		25	25		25	25		25
H5525	085	1	1	04	01	H5525_085_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H5525	085	1	1	04	01	H5525_085_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	25						25			25			25		25
H5525	085	2	1	04	01	H5525_085_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	0		0				25		25	0		0	0		0
H5525	085	2	1	04	01	H5525_085_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	0		0				25		25	0		0	0		0
H5525	085	2	1	04	01	H5525_085_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	25		25				25		25	25		25	25		25
H5525	085	2	1	04	01	H5525_085_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H5525	085	2	1	04	01	H5525_085_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	25						25			25			25		25
H5525	086	1	1	04	01	H5525_086_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	0		0				25		25	0		0	0		0
H5525	086	1	1	04	01	H5525_086_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	086	1	1	04	01	H5525_086_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	25		25				25		25	25		25	25		25
H5525	086	1	1	04	01	H5525_086_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	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	25		25				25		25	25		25	25		25
H5525	086	1	1	04	01	H5525_086_1	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	25						25			25			25		25
H5525	086	2	1	04	01	H5525_086_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	0		0				25		25	0		0	0		0
H5525	086	2	1	04	01	H5525_086_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	086	2	1	04	01	H5525_086_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	25		25				25		25	25		25	25		25
H5525	086	2	1	04	01	H5525_086_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				88.00	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	25		25				25		25	25		25	25		25
H5525	086	2	1	04	01	H5525_086_2	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	25						25			25			25		25
H5525	087	0	1	04	01	H5525_087_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	0		0				25		25	0		0	0		0
H5525	087	0	1	04	01	H5525_087_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5525	087	0	1	04	01	H5525_087_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	25		25				25		25	25		25	25		25
H5525	087	0	1	04	01	H5525_087_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	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	25		25				25		25	25		25	25		25
H5525	087	0	1	04	01	H5525_087_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	25						25			25			25		25
H5526	004	0	1	04	01	H5526_004_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																														
H5526	004	0	1	04	01	H5526_004_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5526	004	0	1	04	01	H5526_004_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											61.66	20		20				61.66	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5526	004	0	1	04	01	H5526_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											59.79	25		25				59.79	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5526	004	0	1	04	01	H5526_004_0	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																														
H5526	016	0	1	04	01	H5526_016_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																														
H5526	016	0	1	04	01	H5526_016_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5526	016	0	1	04	01	H5526_016_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											63.87	20		20				63.87	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H5526	016	0	1	04	01	H5526_016_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											58.64	25		25				58.64	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	20		20	20		20			20			20	20		20
H5526	016	0	1	04	01	H5526_016_0	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																														
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					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	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					3.00		9.00													37.50						7.00				15.00				15.00			0.48	0.10				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											67.65	20		20				67.65	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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											48.61	25		25				48.61	25		25												25						25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
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												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	003	0	1	04	01	H5533_003_0	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	003	0	1	04	01	H5533_003_0	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	003	0	1	04	01	H5533_003_0	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											39.21	25	25	25				63.35	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	003	0	1	04	01	H5533_003_0	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											37.69	44	44	44				32.04	44	44	44										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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	003	0	1	04	01	H5533_003_0	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1527.12	31						717.43	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	005	0	1	04	01	H5533_005_0	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	005	0	1	04	01	H5533_005_0	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	005	0	1	04	01	H5533_005_0	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											35.41	25	25	25				37.76	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	005	0	1	04	01	H5533_005_0	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											35.64	46	46	46				23.68	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	005	0	1	04	01	H5533_005_0	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1549.52	33						661.15	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	008	0	1	04	01	H5533_008_0	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	008	0	1	04	01	H5533_008_0	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	008	0	1	04	01	H5533_008_0	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.64	25	25	25				56.46	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	008	0	1	04	01	H5533_008_0	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											30.58	38	38	38				23.24	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	008	0	1	04	01	H5533_008_0	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1371.65	28						579.15	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	011	0	1	04	01	H5533_011_0	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	011	0	1	04	01	H5533_011_0	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	011	0	1	04	01	H5533_011_0	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											49.64	24	24	24				57.21	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5533	011	0	1	04	01	H5533_011_0	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											22.62	30	30	30				22.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	011	0	1	04	01	H5533_011_0	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1191.61	27						642.80	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	013	0	1	04	01	H5533_013_0	18			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	013	0	1	04	01	H5533_013_0	18			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	013	0	1	04	01	H5533_013_0	18			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											38.63	23	23	23				55.11	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H5533	013	0	1	04	01	H5533_013_0	18			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											22.99	28	28	28				24.65	28	28	28										28	28	28				28	28	28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	013	0	1	04	01	H5533_013_0	18			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1007.50	27						542.83	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	015	1	1	04	01	H5533_015_1	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	1	1	04	01	H5533_015_1	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	1	1	04	01	H5533_015_1	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.82	25	25	25				57.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	1	1	04	01	H5533_015_1	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											32.48	37	37	37				24.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	1	1	04	01	H5533_015_1	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1234.96	28						560.49	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	015	2	1	04	01	H5533_015_2	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	2	1	04	01	H5533_015_2	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	2	1	04	01	H5533_015_2	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.82	25	25	25				57.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	2	1	04	01	H5533_015_2	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											32.48	37	37	37				24.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	2	1	04	01	H5533_015_2	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1234.96	28						560.49	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	015	3	1	04	01	H5533_015_3	17			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	3	1	04	01	H5533_015_3	17			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	3	1	04	01	H5533_015_3	17			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.82	25	25	25				57.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	3	1	04	01	H5533_015_3	17			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											32.48	37	37	37				24.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	3	1	04	01	H5533_015_3	17			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1234.96	28						560.49	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	015	4	1	04	01	H5533_015_4	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	4	1	04	01	H5533_015_4	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	4	1	04	01	H5533_015_4	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.82	25	25	25				57.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	4	1	04	01	H5533_015_4	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											32.48	37	37	37				24.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	4	1	04	01	H5533_015_4	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1234.96	28						560.49	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	015	6	1	04	01	H5533_015_6	16			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	6	1	04	01	H5533_015_6	16			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	015	6	1	04	01	H5533_015_6	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											42.82	25	25	25				57.93	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	6	1	04	01	H5533_015_6	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											32.48	37	37	37				24.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	015	6	1	04	01	H5533_015_6	16			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1234.96	28						560.49	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	017	1	1	04	01	H5533_017_1	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	017	1	1	04	01	H5533_017_1	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	017	1	1	04	01	H5533_017_1	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.05	24	24	24				55.65	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5533	017	1	1	04	01	H5533_017_1	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											22.09	29	29	29				23.35	29	29	29										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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	017	1	1	04	01	H5533_017_1	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1114.51	27						598.10	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5533	017	2	1	04	01	H5533_017_2	15			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		0.50	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	017	2	1	04	01	H5533_017_2	15			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								20.00	40.00	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	25	25	25	0	0	0	25	25	25	0	0	0	25		0
H5533	017	2	1	04	01	H5533_017_2	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.05	24	24	24				55.65	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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5533	017	2	1	04	01	H5533_017_2	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											22.09	29	29	29				23.35	29	29	29										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	96.25	35.00	70.00	105.00	35.00	70.00	87.50	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5533	017	2	1	04	01	H5533_017_2	15			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1114.51	27						598.10	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5549	011	0	1	01	01	H5549_011_0	5		N	Generic	4	01	1	1	1	1	111		01	100		1	30	60	100				1	2			100				30		31				6.01	25	25	25																				25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H5549	011	0	1	01	01	H5549_011_0	5		N	Preferred Brand	4	10	1	1	2	1	111		01	100		1	30	60	100				1	2			100				30		31				77.31	25	25	25																				25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H5549	011	0	1	01	01	H5549_011_0	5		N	Non-Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				28.60	25	25	25																				25															25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H5549	011	0	1	01	01	H5549_011_0	5		N	Specialty Tier	4	11	1	1	4	1	010		01	000		1	30														30		31				192.40	25																																					25			25								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5549	011	0	1	01	01	H5549_011_0	5		N	Select Care Drugs	4	11	1	2	5	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	Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5549	012	0	1	01	01	H5549_012_0	6			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	0	0	0						0				0		0
H5549	012	0	1	01	01	H5549_012_0	6			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	25	25	25						25				25		25
H5549	012	0	1	01	01	H5549_012_0	6			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	25	25	25						25				25		25
H5549	012	0	1	01	01	H5549_012_0	6			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	25	25	25						25				25		25
H5549	012	0	1	01	01	H5549_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				197.45	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5549	012	0	1	01	01	H5549_012_0	6			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	0	0	0						0				0		0
H5577	005	0	1	01	01	H5577_005_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 Drug, Specialty Tier																														
H5577	005	0	1	01	01	H5577_005_0	8			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 Drug, Specialty Tier																														
H5577	005	0	1	01	01	H5577_005_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	005	0	1	01	01	H5577_005_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	7.50	15.00	22.50						15.00				7.50		7.50	25	25	25						25				25		25
H5577	005	0	1	01	01	H5577_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				139.90	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	008	0	1	02	01	H5577_008_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 Drug, Specialty Tier																														
H5577	008	0	1	02	01	H5577_008_0	8			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 Drug, Specialty Tier																														
H5577	008	0	1	02	01	H5577_008_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	008	0	1	02	01	H5577_008_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H5577	008	0	1	02	01	H5577_008_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				182.32	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	038	0	1	01	01	H5577_038_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 Drug, Specialty Tier																														
H5577	038	0	1	01	01	H5577_038_0	8			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 Drug, Specialty Tier																														
H5577	038	0	1	01	01	H5577_038_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	038	0	1	01	01	H5577_038_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	5.00	10.00	15.00						10.00				5.00		5.00	25	25	25						25				25		25
H5577	038	0	1	01	01	H5577_038_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				111.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	042	0	1	01	01	H5577_042_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 Drug, Specialty Tier																														
H5577	042	0	1	01	01	H5577_042_0	8			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 Drug, Specialty Tier																														
H5577	042	0	1	01	01	H5577_042_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	042	0	1	01	01	H5577_042_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H5577	042	0	1	01	01	H5577_042_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				110.21	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	043	0	1	01	01	H5577_043_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 Drug, Specialty Tier																														
H5577	043	0	1	01	01	H5577_043_0	8			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 Drug, Specialty Tier																														
H5577	043	0	1	01	01	H5577_043_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	043	0	1	01	01	H5577_043_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	7.50	15.00	22.50						15.00				7.50		7.50	25	25	25						25				25		25
H5577	043	0	1	01	01	H5577_043_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				180.36	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	044	0	1	01	01	H5577_044_0	10			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 Drug, Specialty Tier																														
H5577	044	0	1	01	01	H5577_044_0	10			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 Drug, Specialty Tier																														
H5577	044	0	1	01	01	H5577_044_0	10			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				2	1			90				30		31	20.00	40.00	60.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00						20.00				10.00		10.00	25	25	25						25				25		25
H5577	044	0	1	01	01	H5577_044_0	10			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	90				2	1			90				30		31	40.00	80.00	120.00																					80.00																40.00				40.00		1.33						1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00						40.00				20.00		20.00	25	25	25						25				25		25
H5577	044	0	1	01	01	H5577_044_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				111.35	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	052	0	1	01	01	H5577_052_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 Drug, Specialty Tier																														
H5577	052	0	1	01	01	H5577_052_0	8			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 Drug, Specialty Tier																														
H5577	052	0	1	01	01	H5577_052_0	8			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	052	0	1	01	01	H5577_052_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	052	0	1	01	01	H5577_052_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				82.99	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	056	1	1	01	01	H5577_056_1	10			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 Drug, Specialty Tier																														
H5577	056	1	1	01	01	H5577_056_1	10			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 Drug, Specialty Tier																														
H5577	056	1	1	01	01	H5577_056_1	10			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	056	1	1	01	01	H5577_056_1	10			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H5577	056	1	1	01	01	H5577_056_1	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				107.18	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	056	2	1	01	01	H5577_056_2	10			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 Drug, Specialty Tier																														
H5577	056	2	1	01	01	H5577_056_2	10			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 Drug, Specialty Tier																														
H5577	056	2	1	01	01	H5577_056_2	10			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	056	2	1	01	01	H5577_056_2	10			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H5577	056	2	1	01	01	H5577_056_2	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				107.18	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	056	4	1	01	01	H5577_056_4	10			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 Drug, Specialty Tier																														
H5577	056	4	1	01	01	H5577_056_4	10			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 Drug, Specialty Tier																														
H5577	056	4	1	01	01	H5577_056_4	10			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	056	4	1	01	01	H5577_056_4	10			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H5577	056	4	1	01	01	H5577_056_4	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				107.18	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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 Drug, Specialty Tier																														
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 Drug, Specialty Tier																														
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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	059	0	1	01	01	H5577_059_0	8			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	15.00	30.00	45.00						30.00				15.00		15.00	25	25	25						25				25		25
H5577	059	0	1	01	01	H5577_059_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				179.02	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5577	060	0	1	01	01	H5577_060_0	9			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 Drug, Specialty Tier																														
H5577	060	0	1	01	01	H5577_060_0	9			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 Drug, Specialty Tier																														
H5577	060	0	1	01	01	H5577_060_0	9			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 Drug, Specialty Tier	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5577	060	0	1	01	01	H5577_060_0	9			Non-Preferred Drug	4	11	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 Drug, Specialty Tier	7.00	14.00	21.00						14.00				7.00		7.00	25	25	25						25				25		25
H5577	060	0	1	01	01	H5577_060_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				187.22	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5590	008	0	1	01	01	H5590_008_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	008	0	1	01	01	H5590_008_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	008	0	1	01	01	H5590_008_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.04	20	20	20				82.04	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5590	008	0	1	01	01	H5590_008_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											39.00	34	34	34				39.00	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5590	008	0	1	01	01	H5590_008_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	008	0	1	01	01	H5590_008_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	010	0	1	01	01	H5590_010_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	010	0	1	01	01	H5590_010_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	010	0	1	01	01	H5590_010_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.06	25	25	25				100.06	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5590	010	0	1	01	01	H5590_010_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5590	010	0	1	01	01	H5590_010_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5590	010	0	1	01	01	H5590_010_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5591	006	1	1	02	01	H5591_006_1	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					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	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					5.00	10.00	15.00					10.00	20.00	25.00																10.00				10.00			0.33	0.17	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5591	006	1	1	02	01	H5591_006_1	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											38.94	25	25	25				44.83	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H5591	006	1	1	02	01	H5591_006_1	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											74.68	32	32	32				59.12	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	006	1	1	02	01	H5591_006_1	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											730.40	29						616.53	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	25			25			25						25		25
H5591	006	1	1	02	01	H5591_006_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								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	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					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	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					5.00	10.00	15.00					10.00	20.00	25.00																10.00				10.00			0.33	0.17	0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5591	006	2	1	02	01	H5591_006_2	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											38.94	25	25	25				44.83	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H5591	006	2	1	02	01	H5591_006_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											74.68	32	32	32				59.12	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	006	2	1	02	01	H5591_006_2	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											730.40	29						616.53	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	25			25			25						25		25
H5591	006	2	1	02	01	H5591_006_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								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	016	0	1	02	01	H5591_016_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					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	016	0	1	02	01	H5591_016_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					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																														
H5591	016	0	1	02	01	H5591_016_0	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											39.48	25	25	25				41.10	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	25	25	25	25	25	25	25	25	25				25		25
H5591	016	0	1	02	01	H5591_016_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											77.38	32	32	32				64.79	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	016	0	1	02	01	H5591_016_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											726.17	29						511.59	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	25			25			25						25		25
H5591	016	0	1	02	01	H5591_016_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								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	017	0	1	02	01	H5591_017_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					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	017	0	1	02	01	H5591_017_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					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																														
H5591	017	0	1	02	01	H5591_017_0	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											39.17	25	25	25				41.82	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	25	25	25	25	25	25	25	25	25				25		25
H5591	017	0	1	02	01	H5591_017_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											66.53	32	32	32				56.51	30	30	30				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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	017	0	1	02	01	H5591_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											750.90	29						481.60	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	25			25			25						25		25
H5591	017	0	1	02	01	H5591_017_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								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	018	0	1	02	01	H5591_018_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								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																														
H5591	018	0	1	02	01	H5591_018_0	5			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								10.00	20.00	30.00					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	018	0	1	02	01	H5591_018_0	5			Preferred Brand	4	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											46.68	25	25	25				50.89	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	018	0	1	02	01	H5591_018_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											78.16	32	32	32				68.38	30	30	30				32	32	32															32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5591	018	0	1	02	01	H5591_018_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											706.44	29						585.30	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H5593	001	0	1	01	01	H5593_001_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5593	001	0	1	01	01	H5593_001_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5593	001	0	1	01	01	H5593_001_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				64.38	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	22	22	22				22	22	22				22		22
H5593	001	0	1	01	01	H5593_001_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				33.03	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5593	001	0	1	01	01	H5593_001_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				419.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5594	001	0	1	01	01	H5594_001_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	001	0	1	01	01	H5594_001_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	001	0	1	01	01	H5594_001_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	001	0	1	01	01	H5594_001_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	002	0	1	01	01	H5594_002_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	002	0	1	01	01	H5594_002_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	002	0	1	01	01	H5594_002_0	5			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	7		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, 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	0	0				0	0	0				0		0
H5594	016	0	1	01	01	H5594_016_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				73.00	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	25	25	25				25	25	25				25		25
H5594	016	0	1	01	01	H5594_016_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				51.00	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	25	25	25				25	25	25				25		25
H5594	016	0	1	01	01	H5594_016_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	016	0	1	01	01	H5594_016_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	017	0	1	01	01	H5594_017_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	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
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				75.00	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	25	25	25				25	25	25				25		25
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				53.00	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	25	25	25				25	25	25				25		25
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	4			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	019	0	1	01	01	H5594_019_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5594	019	0	1	01	01	H5594_019_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5594	019	0	1	01	01	H5594_019_0	4			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	022	0	1	01	01	H5594_022_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	022	0	1	01	01	H5594_022_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	022	0	1	01	01	H5594_022_0	5			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	4			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	026	0	1	01	01	H5594_026_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5594	026	0	1	01	01	H5594_026_0	4			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	25	25	25	25	25	25	25	25	25				25		25
H5594	026	0	1	01	01	H5594_026_0	4			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	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	0	0	0	0	0	0	0	0	0				0		0
H5594	028	0	1	01	01	H5594_028_0	6			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	6			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	25	25	25	25	25	25	25	25	25				25		25
H5594	028	0	1	01	01	H5594_028_0	6			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H5594	028	0	1	01	01	H5594_028_0	6			Select Diabetic Drugs	4	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	25	25	25	25	25	25	25	25	25				25		25
H5594	029	0	1	01	01	H5594_029_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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00				0.00		0.00	0	0	0	0	0	0	0	0	0				0		0
H5594	029	0	1	01	01	H5594_029_0	6			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	25	25	25	25	25	25	25	25	25				25		25
H5594	029	0	1	01	01	H5594_029_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								50.00	100.00	150.00					45.00	90.00	135.00					45.00	90.00	90.00																50.00				50.00			1.67	1.50	1.50			1.47	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	90.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5594	029	0	1	01	01	H5594_029_0	6			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5594	030	0	1	01	01	H5594_030_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	030	0	1	01	01	H5594_030_0	5			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	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	030	0	1	01	01	H5594_030_0	5			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	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	031	0	1	01	01	H5594_031_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	031	0	1	01	01	H5594_031_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	031	0	1	01	01	H5594_031_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	031	0	1	01	01	H5594_031_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	032	0	1	01	01	H5594_032_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	032	0	1	01	01	H5594_032_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	032	0	1	01	01	H5594_032_0	5			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	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	034	0	1	01	01	H5594_034_0	5			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, Select Diabetic Drugs																														
H5594	034	0	1	01	01	H5594_034_0	5			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, 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	25	25	25	25	25	25	25	25	25				25		25
H5594	034	0	1	01	01	H5594_034_0	5			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	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	035	0	1	01	01	H5594_035_0	5			Preferred Generic	4	11	3	2	1	1		111	01	111		1				30	60	100	2	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			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	0	0	0	0	0	0	0	0	0				0		0
H5594	035	0	1	01	01	H5594_035_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	035	0	1	01	01	H5594_035_0	5			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	25	25	25	25	25	25	25	25	25				25		25
H5594	035	0	1	01	01	H5594_035_0	5			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	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	0	0	0	0	0	0	0	0	0				0		0
H5594	036	0	1	01	01	H5594_036_0	6			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	6			Non-Preferred Drug	4	11	3	2	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								45.00	90.00	135.00					40.00	80.00	120.00					40.00	80.00	80.00																45.00				45.00			1.50	1.33	1.33			1.32	Preferred Generic, 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	80.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5594	036	0	1	01	01	H5594_036_0	6			Specialty Tier	4	11	1	1	4	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H5594	036	0	1	01	01	H5594_036_0	6			Select Diabetic Drugs	4	11	1	2	5	1		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	0	0	0	0	0	0	0	0	0				0		0
H5599	002	0	1	02	01	H5599_002_0	9			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	002	0	1	02	01	H5599_002_0	9			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	9			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											96.08	23	23	23				96.08	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		70.00	105.00		70.00	105.00	35.00		35.00	23	23	23	23	23	23		23	23		23	23	23		23
H5599	002	0	1	02	01	H5599_002_0	9			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	002	0	1	02	01	H5599_002_0	9			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	9			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	003	0	1	01	01	H5599_003_0	9		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	003	0	1	01	01	H5599_003_0	9		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	003	0	1	01	01	H5599_003_0	9		N	Preferred Brand	3	11	1	2	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					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	105.00		70.00	105.00		70.00	94.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	003	0	1	01	01	H5599_003_0	9		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											48.69	31	31	31				48.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	003	0	1	01	01	H5599_003_0	9		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	003	0	1	01	01	H5599_003_0	9		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5599	004	0	1	02	01	H5599_004_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5599	004	0	1	02	01	H5599_004_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											122.36	25	25	25				122.36	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	004	0	1	02	01	H5599_004_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.24	39	39	39				82.24	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	004	0	1	02	01	H5599_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	004	0	1	02	01	H5599_004_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	1	1	01	01	H5599_013_1	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	1	1	01	01	H5599_013_1	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	1	1	01	01	H5599_013_1	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.57	20	20	20				86.57	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5599	013	1	1	01	01	H5599_013_1	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	013	1	1	01	01	H5599_013_1	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	1	1	01	01	H5599_013_1	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	2	1	01	01	H5599_013_2	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	2	1	01	01	H5599_013_2	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	2	1	01	01	H5599_013_2	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											86.57	20	20	20				86.57	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5599	013	2	1	01	01	H5599_013_2	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5599	013	2	1	01	01	H5599_013_2	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5599	013	2	1	01	01	H5599_013_2	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			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	25	25	25	25	25	25			25			25	25		25
H5608	002	0	1	01	01	H5608_002_0	7			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	25	25	25	25	25	25			25			25	25		25
H5608	002	0	1	01	01	H5608_002_0	7			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	25	25	25	25	25	25			25			25	25		25
H5608	002	0	1	01	01	H5608_002_0	7			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	25	25	25	25	25	25			25			25	25		25
H5608	002	0	1	01	01	H5608_002_0	7			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											762.71	33						360.23	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	25			25			25			25			25		25
H5608	002	0	1	01	01	H5608_002_0	7			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	25	25	25	25	25	25			25			25	25		25
H5619	001	0	1	01	01	H5619_001_0	2			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	0		0				25		25	0		0	0		0
H5619	001	0	1	01	01	H5619_001_0	2			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	25		25				25		25	25		0	25		25
H5619	001	0	1	01	01	H5619_001_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	001	0	1	01	01	H5619_001_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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	25		25				25		25	25		25	25		25
H5619	001	0	1	01	01	H5619_001_0	2			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	25						25			25			25		25
H5619	003	0	1	01	01	H5619_003_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	0		0				25		25	0		0	0		0
H5619	003	0	1	01	01	H5619_003_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	0		0				25		25	0		0	0		0
H5619	003	0	1	01	01	H5619_003_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	003	0	1	01	01	H5619_003_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	003	0	1	01	01	H5619_003_0	5		N	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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	012	0	1	01	01	H5619_012_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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	015	0	1	01	01	H5619_015_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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				97.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	016	0	1	01	01	H5619_016_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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	021	0	1	01	01	H5619_021_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	0		0				25		25	0		0	0		0
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	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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5619	026	0	1	01	01	H5619_026_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	0		0				25		25	0		0	0		0
H5619	026	0	1	01	01	H5619_026_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	026	0	1	01	01	H5619_026_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	25		25				25		25	25		25	25		25
H5619	026	0	1	01	01	H5619_026_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5619	026	0	1	01	01	H5619_026_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	25						25			25			25		25
H5619	038	0	1	01	01	H5619_038_0	6		N	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	0		0				25		25	0		0	0		0
H5619	038	0	1	01	01	H5619_038_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	0		0				25		25	0		0	0		0
H5619	038	0	1	01	01	H5619_038_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	038	0	1	01	01	H5619_038_0	6		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5619	038	0	1	01	01	H5619_038_0	6		N	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	25						25			25			25		25
H5619	046	0	1	01	01	H5619_046_0	2			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	0		0				25		25	0		0	0		0
H5619	046	0	1	01	01	H5619_046_0	2			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	25		25				25		25	25		0	25		25
H5619	046	0	1	01	01	H5619_046_0	2			Preferred Brand	4	11	1	2	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	046	0	1	01	01	H5619_046_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				59.00	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	25		25				25		25	25		25	25		25
H5619	046	0	1	01	01	H5619_046_0	2			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	25						25			25			25		25
H5619	046	0	1	01	01	H5619_046_0	2			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	0		0				0		0	0		0	0		0
H5619	047	0	1	01	01	H5619_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	0		0				25		25	0		0	0		0
H5619	047	0	1	01	01	H5619_047_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	047	0	1	01	01	H5619_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	25		25				25		25	25		25	25		25
H5619	047	0	1	01	01	H5619_047_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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	25		25				25		25	25		25	25		25
H5619	047	0	1	01	01	H5619_047_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	25						25			25			25		25
H5619	049	0	1	02	01	H5619_049_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	0		0				25		25	0		0	0		0
H5619	049	0	1	02	01	H5619_049_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	0		0				25		25	0		0	0		0
H5619	049	0	1	02	01	H5619_049_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	25		25				25		25	25		25	25		25
H5619	049	0	1	02	01	H5619_049_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	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5619	051	0	1	02	01	H5619_051_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	0		0				25		25	0		0	0		0
H5619	051	0	1	02	01	H5619_051_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	051	0	1	02	01	H5619_051_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	25		25				25		25	25		25	25		25
H5619	051	0	1	02	01	H5619_051_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5619	051	0	1	02	01	H5619_051_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	25						25			25			25		25
H5619	053	0	1	02	01	H5619_053_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	0		0				25		25	0		0	0		0
H5619	053	0	1	02	01	H5619_053_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	053	0	1	02	01	H5619_053_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	25		25				25		25	25		25	25		25
H5619	053	0	1	02	01	H5619_053_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5619	053	0	1	02	01	H5619_053_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	25						25			25			25		25
H5619	055	0	1	01	01	H5619_055_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	0		0				25		25	0		0	0		0
H5619	055	0	1	01	01	H5619_055_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	25		25				25		25	25		0	25		25
H5619	055	0	1	01	01	H5619_055_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		94.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	055	0	1	01	01	H5619_055_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				52.00	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	25		25				25		25	25		25	25		25
H5619	055	0	1	01	01	H5619_055_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	055	0	1	01	01	H5619_055_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	0		0				25		25	0		0	0		0
H5619	057	0	1	01	01	H5619_057_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	0		0				25		25	0		0	0		0
H5619	057	0	1	01	01	H5619_057_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	057	0	1	01	01	H5619_057_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	25		25				25		25	25		25	25		25
H5619	057	0	1	01	01	H5619_057_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	25		25				25		25	25		25	25		25
H5619	057	0	1	01	01	H5619_057_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	25						25			25			25		25
H5619	059	0	1	01	01	H5619_059_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	0		0				25		25	0		0	0		0
H5619	059	0	1	01	01	H5619_059_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5619	061	0	1	01	01	H5619_061_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	0		0				25		25	0		0	0		0
H5619	061	0	1	01	01	H5619_061_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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	066	0	1	01	01	H5619_066_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	0		0				25		25	0		0	0		0
H5619	066	0	1	01	01	H5619_066_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5619	066	0	1	01	01	H5619_066_0	3			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	46.00		138.00																									47.00		141.00				46.00		128.00				46.00				46.00		1.53				1.57	1.53	1.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	066	0	1	01	01	H5619_066_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	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	25		25				25		25	25		25	25		25
H5619	066	0	1	01	01	H5619_066_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	25						25			25			25		25
H5619	069	0	1	02	01	H5619_069_0	2			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	0		0				25		25	0		0	0		0
H5619	069	0	1	02	01	H5619_069_0	2			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	25		25				25		25	25		0	25		25
H5619	069	0	1	02	01	H5619_069_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	069	0	1	02	01	H5619_069_0	2			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	25		25				25		25	25		25	25		25
H5619	069	0	1	02	01	H5619_069_0	2			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	25						25			25			25		25
H5619	071	0	1	01	01	H5619_071_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	0		0				25		25	0		0	0		0
H5619	071	0	1	01	01	H5619_071_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	0		0				25		25	0		0	0		0
H5619	071	0	1	01	01	H5619_071_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	25		25				25		25	25		25	25		25
H5619	071	0	1	01	01	H5619_071_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	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	25		25				25		25	25		25	25		25
H5619	071	0	1	01	01	H5619_071_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	25						25			25			25		25
H5619	075	0	1	01	01	H5619_075_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	0		0				25		25	0		0	0		0
H5619	075	0	1	01	01	H5619_075_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	0		0				25		25	0		0	0		0
H5619	075	0	1	01	01	H5619_075_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	075	0	1	01	01	H5619_075_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	075	0	1	01	01	H5619_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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	083	0	1	01	01	H5619_083_0	2			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	0		0				25		25	0		0	0		0
H5619	083	0	1	01	01	H5619_083_0	2			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	25		25				25		25	25		0	25		25
H5619	083	0	1	01	01	H5619_083_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	083	0	1	01	01	H5619_083_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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	25		25				25		25	25		25	25		25
H5619	083	0	1	01	01	H5619_083_0	2			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	25						25			25			25		25
H5619	089	0	1	01	01	H5619_089_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	0		0				25		25	0		0	0		0
H5619	089	0	1	01	01	H5619_089_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	089	0	1	01	01	H5619_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	25		25				25		25	25		25	25		25
H5619	089	0	1	01	01	H5619_089_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5619	089	0	1	01	01	H5619_089_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	25						25			25			25		25
H5619	090	0	1	01	01	H5619_090_0	2			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	0		0				25		25	0		0	0		0
H5619	090	0	1	01	01	H5619_090_0	2			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	0		0				25		25	0		0	0		0
H5619	090	0	1	01	01	H5619_090_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	090	0	1	01	01	H5619_090_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				65.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	090	0	1	01	01	H5619_090_0	2			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	25						25			25			25		25
H5619	091	0	1	01	01	H5619_091_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	0		0				25		25	0		0	0		0
H5619	091	0	1	01	01	H5619_091_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	091	0	1	01	01	H5619_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	25		25				25		25	25		25	25		25
H5619	091	0	1	01	01	H5619_091_0	3			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	25		25				25		25	25		25	25		25
H5619	091	0	1	01	01	H5619_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	25						25			25			25		25
H5619	093	0	1	01	01	H5619_093_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	0		0				25		25	0		0	0		0
H5619	093	0	1	01	01	H5619_093_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	0		0				25		25	0		0	0		0
H5619	093	0	1	01	01	H5619_093_0	5		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H5619	093	0	1	01	01	H5619_093_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	093	0	1	01	01	H5619_093_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	25						25			25			25		25
H5619	095	0	1	01	01	H5619_095_0	2			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	0		0				25		25	0		0	0		0
H5619	095	0	1	01	01	H5619_095_0	2			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	25		25				25		25	25		0	25		25
H5619	095	0	1	01	01	H5619_095_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	095	0	1	01	01	H5619_095_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				64.00	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	25		25				25		25	25		25	25		25
H5619	095	0	1	01	01	H5619_095_0	2			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	25						25			25			25		25
H5619	111	0	1	02	01	H5619_111_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	0		0				25		25	0		0	0		0
H5619	111	0	1	02	01	H5619_111_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	111	0	1	02	01	H5619_111_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	25		25				25		25	25		25	25		25
H5619	111	0	1	02	01	H5619_111_0	3			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	25		25				25		25	25		25	25		25
H5619	111	0	1	02	01	H5619_111_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	25						25			25			25		25
H5619	113	0	1	02	01	H5619_113_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	0		0				25		25	0		0	0		0
H5619	113	0	1	02	01	H5619_113_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	0		0				25		25	0		0	0		0
H5619	113	0	1	02	01	H5619_113_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	25		25				25		25	25		25	25		25
H5619	113	0	1	02	01	H5619_113_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	113	0	1	02	01	H5619_113_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	25						25			25			25		25
H5619	116	0	1	01	01	H5619_116_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	0		0				25		25	0		0	0		0
H5619	116	0	1	01	01	H5619_116_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	25		25				25		25	25		0	25		25
H5619	116	0	1	01	01	H5619_116_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	25		25				25		25	25		25	25		25
H5619	116	0	1	01	01	H5619_116_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	116	0	1	01	01	H5619_116_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	25						25			25			25		25
H5619	119	0	1	01	01	H5619_119_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	0		0				25		25	0		0	0		0
H5619	119	0	1	01	01	H5619_119_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	25		25				25		25	25		0	25		25
H5619	119	0	1	01	01	H5619_119_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	25		25				25		25	25		25	25		25
H5619	119	0	1	01	01	H5619_119_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	119	0	1	01	01	H5619_119_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	25						25			25			25		25
H5619	122	0	1	01	01	H5619_122_0	2			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	0		0				25		25	0		0	0		0
H5619	122	0	1	01	01	H5619_122_0	2			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	25		25				25		25	25		0	25		25
H5619	122	0	1	01	01	H5619_122_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	122	0	1	01	01	H5619_122_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H5619	122	0	1	01	01	H5619_122_0	2			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	25						25			25			25		25
H5619	123	0	1	02	01	H5619_123_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	0		0				25		25	0		0	0		0
H5619	123	0	1	02	01	H5619_123_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	0		0				25		25	0		0	0		0
H5619	123	0	1	02	01	H5619_123_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	123	0	1	02	01	H5619_123_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	123	0	1	02	01	H5619_123_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	25						25			25			25		25
H5619	126	0	1	02	01	H5619_126_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	0		0				25		25	0		0	0		0
H5619	126	0	1	02	01	H5619_126_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	0		0				25		25	0		0	0		0
H5619	126	0	1	02	01	H5619_126_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	126	0	1	02	01	H5619_126_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	126	0	1	02	01	H5619_126_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	25						25			25			25		25
H5619	133	0	1	01	01	H5619_133_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	0		0				25		25	0		0	0		0
H5619	133	0	1	01	01	H5619_133_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	25		25				25		25	25		0	25		25
H5619	133	0	1	01	01	H5619_133_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	25		25				25		25	25		25	25		25
H5619	133	0	1	01	01	H5619_133_0	3			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	25		25				25		25	25		25	25		25
H5619	133	0	1	01	01	H5619_133_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	25						25			25			25		25
H5619	135	0	1	01	01	H5619_135_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	0		0				25		25	0		0	0		0
H5619	135	0	1	01	01	H5619_135_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	135	0	1	01	01	H5619_135_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	25		25				25		25	25		25	25		25
H5619	135	0	1	01	01	H5619_135_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
H5619	135	0	1	01	01	H5619_135_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	25						25			25			25		25
H5619	137	0	1	01	01	H5619_137_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	0		0				25		25	0		0	0		0
H5619	137	0	1	01	01	H5619_137_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	137	0	1	01	01	H5619_137_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	25		25				25		25	25		25	25		25
H5619	137	0	1	01	01	H5619_137_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	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	25		25				25		25	25		25	25		25
H5619	137	0	1	01	01	H5619_137_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	145	0	1	01	01	H5619_145_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	0		0				25		25	0		0	0		0
H5619	145	0	1	01	01	H5619_145_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	25		25				25		25	25		0	25		25
H5619	145	0	1	01	01	H5619_145_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	145	0	1	01	01	H5619_145_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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	25		25				25		25	25		25	25		25
H5619	145	0	1	01	01	H5619_145_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	145	0	1	01	01	H5619_145_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	0		0				0		0	0		0	0		0
H5619	146	0	1	01	01	H5619_146_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	0		0				25		25	0		0	0		0
H5619	146	0	1	01	01	H5619_146_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	0		0				25		25	0		0	0		0
H5619	146	0	1	01	01	H5619_146_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	25		25				25		25	25		25	25		25
H5619	146	0	1	01	01	H5619_146_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				46.00	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	25		25				25		25	25		25	25		25
H5619	146	0	1	01	01	H5619_146_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	25						25			25			25		25
H5619	147	0	1	01	01	H5619_147_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	0		0				25		25	0		0	0		0
H5619	147	0	1	01	01	H5619_147_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5619	147	0	1	01	01	H5619_147_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	33.00		99.00																									47.00		141.00				33.00		66.00				33.00				33.00		1.10				1.57	1.10	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	33.00		99.00				35.00		105.00	33.00		66.00	33.00		33.00	25		25				25		25	25		25	25		25
H5619	147	0	1	01	01	H5619_147_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	147	0	1	01	01	H5619_147_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	148	0	1	01	01	H5619_148_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	25		25				25		25	25		0	25		25
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	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H5619	150	0	1	01	01	H5619_150_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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				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		35.00	25		25				25		25	25		25	25		25
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					33																										33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5619	152	0	1	01	01	H5619_152_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	0		0				25		25	0		0	0		0
H5619	152	0	1	01	01	H5619_152_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	0		0				25		25	0		0	0		0
H5619	152	0	1	01	01	H5619_152_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	25		25				25		25	25		25	25		25
H5619	152	0	1	01	01	H5619_152_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	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	25		25				25		25	25		25	25		25
H5619	152	0	1	01	01	H5619_152_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	25						25			25			25		25
H5619	157	0	1	01	01	H5619_157_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	0		0				25		25	0		0	0		0
H5619	157	0	1	01	01	H5619_157_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	157	0	1	01	01	H5619_157_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	25		25				25		25	25		25	25		25
H5619	157	0	1	01	01	H5619_157_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	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	25		25				25		25	25		25	25		25
H5619	157	0	1	01	01	H5619_157_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	25						25			25			25		25
H5619	159	0	1	01	01	H5619_159_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	0		0				25		25	0		0	0		0
H5619	159	0	1	01	01	H5619_159_0	5			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	8.00		24.00																									20.00		60.00				8.00		0.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	8.00		24.00				20.00		60.00	8.00		0.00	8.00		8.00	25		25				25		25	25		0	25		25
H5619	159	0	1	01	01	H5619_159_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	25		25				25		25	25		25	25		25
H5619	159	0	1	01	01	H5619_159_0	5			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	25		25				25		25	25		25	25		25
H5619	159	0	1	01	01	H5619_159_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	25						25			25			25		25
H5619	161	0	1	01	01	H5619_161_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				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
H5619	161	0	1	01	01	H5619_161_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	0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
H5619	161	0	1	01	01	H5619_161_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, Select Care Drugs	0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
H5619	161	0	1	01	01	H5619_161_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				47.00	48		48																								48		48				48		48			48			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	0		0				0		0	0		0	0		0
H5619	161	0	1	01	01	H5619_161_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	0.00						0.00			0.00			0.00		0.00	0						0			0			0		0
H5619	161	0	1	01	01	H5619_161_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	0		0				0		0	0		0	0		0
H5619	162	0	1	02	01	H5619_162_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	0		0				25		25	0		0	0		0
H5619	162	0	1	02	01	H5619_162_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	0		0				25		25	0		0	0		0
H5619	162	0	1	02	01	H5619_162_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	162	0	1	02	01	H5619_162_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	162	0	1	02	01	H5619_162_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	25						25			25			25		25
H5619	163	0	1	01	01	H5619_163_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	0		0				25		25	0		0	0		0
H5619	163	0	1	01	01	H5619_163_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	0		0				25		25	0		0	0		0
H5619	163	0	1	01	01	H5619_163_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	163	0	1	01	01	H5619_163_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H5619	163	0	1	01	01	H5619_163_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	25						25			25			25		25
H5619	165	0	1	01	01	H5619_165_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	0		0				25		25	0		0	0		0
H5619	165	0	1	01	01	H5619_165_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	0		0				25		25	0		0	0		0
H5619	165	0	1	01	01	H5619_165_0	6		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H5619	165	0	1	01	01	H5619_165_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				67.00	25		25																								25		25				25		25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	165	0	1	01	01	H5619_165_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	25						25			25			25		25
H5619	166	0	1	01	01	H5619_166_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	0		0				25		25	0		0	0		0
H5619	166	0	1	01	01	H5619_166_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	0		0				25		25	0		0	0		0
H5619	166	0	1	01	01	H5619_166_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	166	0	1	01	01	H5619_166_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	166	0	1	01	01	H5619_166_0	5		N	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	25						25			25			25		25
H5619	167	0	1	01	01	H5619_167_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	0		0				25		25	0		0	0		0
H5619	167	0	1	01	01	H5619_167_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	0		0				25		25	0		0	0		0
H5619	167	0	1	01	01	H5619_167_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	167	0	1	01	01	H5619_167_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	167	0	1	01	01	H5619_167_0	5		N	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	25						25			25			25		25
H5619	169	0	1	01	01	H5619_169_0	2			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	0		0				25		25	0		0	0		0
H5619	169	0	1	01	01	H5619_169_0	2			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	0		0				25		25	0		0	0		0
H5619	169	0	1	01	01	H5619_169_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	169	0	1	01	01	H5619_169_0	2			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	25		25				25		25	25		25	25		25
H5619	169	0	1	01	01	H5619_169_0	2			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	25						25			25			25		25
H5619	170	0	1	01	01	H5619_170_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	0		0				25		25	0		0	0		0
H5619	170	0	1	01	01	H5619_170_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H5619	170	0	1	01	01	H5619_170_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	25		25				25		25	25		25	25		25
H5619	170	0	1	01	01	H5619_170_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	170	0	1	01	01	H5619_170_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	25						25			25			25		25
H5619	170	0	1	01	01	H5619_170_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	0		0				25		25	0		0	0		0
H5619	171	0	1	01	01	H5619_171_0	2			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	0		0				25		25	0		0	0		0
H5619	171	0	1	01	01	H5619_171_0	2			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	0		0				25		25	0		0	0		0
H5619	171	0	1	01	01	H5619_171_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	171	0	1	01	01	H5619_171_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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	25		25				25		25	25		25	25		25
H5619	171	0	1	01	01	H5619_171_0	2			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	25						25			25			25		25
H5619	173	0	1	01	01	H5619_173_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	0		0				25		25	0		0	0		0
H5619	173	0	1	01	01	H5619_173_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5619	173	0	1	01	01	H5619_173_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	25		25				25		25	25		25	25		25
H5619	173	0	1	01	01	H5619_173_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	45		45																								45		45				45		45			45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
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	25						25			25			25		25
H5619	174	0	1	01	01	H5619_174_0	2			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	0		0				25		25	0		0	0		0
H5619	174	0	1	01	01	H5619_174_0	2			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	25		25				25		25	25		0	25		25
H5619	174	0	1	01	01	H5619_174_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	174	0	1	01	01	H5619_174_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H5619	174	0	1	01	01	H5619_174_0	2			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	25						25			25			25		25
H5619	177	0	1	01	01	H5619_177_0	2			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	0		0				25		25	0		0	0		0
H5619	177	0	1	01	01	H5619_177_0	2			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	25		25				25		25	25		0	25		25
H5619	177	0	1	01	01	H5619_177_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	177	0	1	01	01	H5619_177_0	2			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	25		25				25		25	25		25	25		25
H5619	177	0	1	01	01	H5619_177_0	2			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	25						25			25			25		25
H5619	178	0	1	01	01	H5619_178_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	0		0				25		25	0		0	0		0
H5619	178	0	1	01	01	H5619_178_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	0		0				25		25	0		0	0		0
H5619	178	0	1	01	01	H5619_178_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	25		25				25		25	25		25	25		25
H5619	178	0	1	01	01	H5619_178_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	25		25				25		25	25		25	25		25
H5619	178	0	1	01	01	H5619_178_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	25						25			25			25		25
H5619	179	0	1	02	01	H5619_179_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	0		0				25		25	0		0	0		0
H5619	179	0	1	02	01	H5619_179_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	0		0				25		25	0		0	0		0
H5619	179	0	1	02	01	H5619_179_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	179	0	1	02	01	H5619_179_0	4		N	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	25		25				25		25	25		25	25		25
H5619	179	0	1	02	01	H5619_179_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	25						25			25			25		25
H5619	180	0	1	01	01	H5619_180_0	2			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	0		0				25		25	0		0	0		0
H5619	180	0	1	01	01	H5619_180_0	2			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	25		25				25		25	25		0	25		25
H5619	180	0	1	01	01	H5619_180_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H5619	180	0	1	01	01	H5619_180_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				86.00	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	25		25				25		25	25		25	25		25
H5619	180	0	1	01	01	H5619_180_0	2			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	25						25			25			25		25
H5619	181	0	1	01	01	H5619_181_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	0		0				25		25	0		0	0		0
H5619	181	0	1	01	01	H5619_181_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	25		25				25		25	25		0	25		25
H5619	181	0	1	01	01	H5619_181_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	181	0	1	01	01	H5619_181_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	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	25		25				25		25	25		25	25		25
H5619	181	0	1	01	01	H5619_181_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	25						25			25			25		25
H5619	181	0	1	01	01	H5619_181_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	0		0				0		0	0		0	0		0
H5619	182	0	1	01	01	H5619_182_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	0		0				25		25	0		0	0		0
H5619	182	0	1	01	01	H5619_182_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	0		0				25		25	0		0	0		0
H5619	182	0	1	01	01	H5619_182_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	182	0	1	01	01	H5619_182_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H5619	182	0	1	01	01	H5619_182_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	25						25			25			25		25
H5619	183	0	1	01	01	H5619_183_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	0		0				25		25	0		0	0		0
H5619	183	0	1	01	01	H5619_183_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	25		25				25		25	25		0	25		25
H5619	183	0	1	01	01	H5619_183_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	25		25				25		25	25		25	25		25
H5619	183	0	1	01	01	H5619_183_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	25		25				25		25	25		25	25		25
H5619	183	0	1	01	01	H5619_183_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	25						25			25			25		25
H5619	184	0	1	01	01	H5619_184_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	0		0				25		25	0		0	0		0
H5619	184	0	1	01	01	H5619_184_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	0		0				25		25	0		0	0		0
H5619	184	0	1	01	01	H5619_184_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	25		25				25		25	25		25	25		25
H5619	184	0	1	01	01	H5619_184_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	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	25		25				25		25	25		25	25		25
H5619	184	0	1	01	01	H5619_184_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	25						25			25			25		25
H5628	001	0	1	01	01	H5628_001_0	8		N	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																														
H5628	001	0	1	01	01	H5628_001_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				2.38	10	10	10																		10	10	10															10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	001	0	1	01	01	H5628_001_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				27.44	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	20	20	20				20	20	20				20		20
H5628	001	0	1	01	01	H5628_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.24	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		35.00	25	25	25				25	25	25				25		25
H5628	001	0	1	01	01	H5628_001_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				620.85	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	25						25						25		25
H5628	001	0	1	01	01	H5628_001_0	8		N	Select Care Drugs	4	01	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																														
H5628	012	0	1	01	01	H5628_012_0	8		N	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																														
H5628	012	0	1	01	01	H5628_012_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	012	0	1	01	01	H5628_012_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.14	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	20	20	20				20	20	20				20		20
H5628	012	0	1	01	01	H5628_012_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				64.40	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		35.00	25	25	25				25	25	25				25		25
H5628	012	0	1	01	01	H5628_012_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				730.72	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	25						25						25		25
H5628	012	0	1	01	01	H5628_012_0	8		N	Select Care Drugs	4	01	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																														
H5628	013	1	1	01	01	H5628_013_1	9		N	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																														
H5628	013	1	1	01	01	H5628_013_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.68	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	013	1	1	01	01	H5628_013_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.85	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	20	20	20				20	20	20				20		20
H5628	013	1	1	01	01	H5628_013_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				59.74	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		35.00	25	25	25				25	25	25				25		25
H5628	013	1	1	01	01	H5628_013_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				471.04	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	25						25						25		25
H5628	013	1	1	01	01	H5628_013_1	9		N	Select Care Drugs	4	01	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																														
H5628	013	2	1	01	01	H5628_013_2	9		N	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																														
H5628	013	2	1	01	01	H5628_013_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.68	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	013	2	1	01	01	H5628_013_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.85	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	20	20	20				20	20	20				20		20
H5628	013	2	1	01	01	H5628_013_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				59.74	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		35.00	25	25	25				25	25	25				25		25
H5628	013	2	1	01	01	H5628_013_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				471.04	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	25						25						25		25
H5628	013	2	1	01	01	H5628_013_2	9		N	Select Care Drugs	4	01	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																														
H5628	014	1	1	01	01	H5628_014_1	9		N	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																														
H5628	014	1	1	01	01	H5628_014_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.64	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	014	1	1	01	01	H5628_014_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.09	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	20	20	20				20	20	20				20		20
H5628	014	1	1	01	01	H5628_014_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				71.87	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		35.00	25	25	25				25	25	25				25		25
H5628	014	1	1	01	01	H5628_014_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				728.79	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	25						25						25		25
H5628	014	1	1	01	01	H5628_014_1	9		N	Select Care Drugs	4	01	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																														
H5628	014	2	1	01	01	H5628_014_2	9		N	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																														
H5628	014	2	1	01	01	H5628_014_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.64	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5628	014	2	1	01	01	H5628_014_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.09	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	20	20	20				20	20	20				20		20
H5628	014	2	1	01	01	H5628_014_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				71.87	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		35.00	25	25	25				25	25	25				25		25
H5628	014	2	1	01	01	H5628_014_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				728.79	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	25						25						25		25
H5628	014	2	1	01	01	H5628_014_2	9		N	Select Care Drugs	4	01	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																														
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	25	25	25				25	25	25				25		25
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	35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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				957.68	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5649	001	0	1	01	01	H5649_001_0	8			Select Care Drugs	4	01	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	009	0	1	01	01	H5649_009_0	8		N	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	009	0	1	01	01	H5649_009_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	4.00	8.00	8.00																			4.00	8.00	8.00																4.00				4.00		0.13			0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	009	0	1	01	01	H5649_009_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				38.23	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	20	20	20				20	20	20				20		20
H5649	009	0	1	01	01	H5649_009_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				70.93	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		35.00	25	25	25				25	25	25				25		25
H5649	009	0	1	01	01	H5649_009_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				718.33	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	25						25						25		25
H5649	009	0	1	01	01	H5649_009_0	8		N	Select Care Drugs	4	01	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																														
H5649	018	0	1	01	01	H5649_018_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	018	0	1	01	01	H5649_018_0	9			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	018	0	1	01	01	H5649_018_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	25	25	25				25	25	25				25		25
H5649	018	0	1	01	01	H5649_018_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	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	35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H5649	018	0	1	01	01	H5649_018_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				500.28	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	25						25						25		25
H5649	018	0	1	01	01	H5649_018_0	9			Select Care Drugs	4	01	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	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	022	0	1	01	01	H5649_022_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	022	0	1	01	01	H5649_022_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	25	25	25				25	25	25				25		25
H5649	022	0	1	01	01	H5649_022_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				55.75	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	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H5649	022	0	1	01	01	H5649_022_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				372.31	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5649	022	0	1	01	01	H5649_022_0	8			Select Care Drugs	4	01	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	10			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	10			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	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.37	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	023	0	1	01	01	H5649_023_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.56	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		35.00	25	25	25				25	25	25				25		25
H5649	023	0	1	01	01	H5649_023_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				473.65	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	25						25						25		25
H5649	023	0	1	01	01	H5649_023_0	10			Select Care Drugs	4	01	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	024	0	1	01	01	H5649_024_0	9		N	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	024	0	1	01	01	H5649_024_0	9		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	024	0	1	01	01	H5649_024_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.21	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		35.00	20	20	20				20	20	20				20		20
H5649	024	0	1	01	01	H5649_024_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				74.16	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		35.00	25	25	25				25	25	25				25		25
H5649	024	0	1	01	01	H5649_024_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				769.71	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	25						25						25		25
H5649	024	0	1	01	01	H5649_024_0	9		N	Select Care Drugs	4	01	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																														
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	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				7.18	15	15	15																		15	15	15															15			15								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	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				38.55	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	025	1	1	01	01	H5649_025_1	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.24	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		35.00	25	25	25				25	25	25				25		25
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				773.74	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	25						25						25		25
H5649	025	1	1	01	01	H5649_025_1	8			Select Care Drugs	4	01	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	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	025	2	1	01	01	H5649_025_2	9			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				7.18	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	025	2	1	01	01	H5649_025_2	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				38.55	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	025	2	1	01	01	H5649_025_2	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.24	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		35.00	25	25	25				25	25	25				25		25
H5649	025	2	1	01	01	H5649_025_2	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				773.74	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	25						25						25		25
H5649	025	2	1	01	01	H5649_025_2	9			Select Care Drugs	4	01	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	3	1	01	01	H5649_025_3	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	025	3	1	01	01	H5649_025_3	9			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				7.18	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	025	3	1	01	01	H5649_025_3	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				38.55	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	025	3	1	01	01	H5649_025_3	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.24	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		35.00	25	25	25				25	25	25				25		25
H5649	025	3	1	01	01	H5649_025_3	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				773.74	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	25						25						25		25
H5649	025	3	1	01	01	H5649_025_3	9			Select Care Drugs	4	01	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	4	1	01	01	H5649_025_4	10			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	4	1	01	01	H5649_025_4	10			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				7.18	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	025	4	1	01	01	H5649_025_4	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				38.55	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	025	4	1	01	01	H5649_025_4	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				63.24	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		35.00	25	25	25				25	25	25				25		25
H5649	025	4	1	01	01	H5649_025_4	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				773.74	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	25						25						25		25
H5649	025	4	1	01	01	H5649_025_4	10			Select Care Drugs	4	01	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	026	1	1	01	01	H5649_026_1	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	026	1	1	01	01	H5649_026_1	9			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.43	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	026	1	1	01	01	H5649_026_1	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.22	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	026	1	1	01	01	H5649_026_1	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				68.20	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		35.00	25	25	25				25	25	25				25		25
H5649	026	1	1	01	01	H5649_026_1	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				764.53	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	25						25						25		25
H5649	026	1	1	01	01	H5649_026_1	9			Select Care Drugs	4	01	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																														
H5649	026	2	1	01	01	H5649_026_2	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	026	2	1	01	01	H5649_026_2	9			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.43	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	026	2	1	01	01	H5649_026_2	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.22	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	026	2	1	01	01	H5649_026_2	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				68.20	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		35.00	25	25	25				25	25	25				25		25
H5649	026	2	1	01	01	H5649_026_2	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				764.53	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	25						25						25		25
H5649	026	2	1	01	01	H5649_026_2	9			Select Care Drugs	4	01	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																														
H5649	026	3	1	01	01	H5649_026_3	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	026	3	1	01	01	H5649_026_3	9			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.43	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	026	3	1	01	01	H5649_026_3	9			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.22	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	026	3	1	01	01	H5649_026_3	9			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				68.20	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		35.00	25	25	25				25	25	25				25		25
H5649	026	3	1	01	01	H5649_026_3	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				764.53	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	25						25						25		25
H5649	026	3	1	01	01	H5649_026_3	9			Select Care Drugs	4	01	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																														
H5649	026	4	1	01	01	H5649_026_4	10			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	026	4	1	01	01	H5649_026_4	10			Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.43	15	15	15																		15	15	15															15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	026	4	1	01	01	H5649_026_4	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.22	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	026	4	1	01	01	H5649_026_4	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				68.20	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		35.00	25	25	25				25	25	25				25		25
H5649	026	4	1	01	01	H5649_026_4	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				764.53	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	25						25						25		25
H5649	026	4	1	01	01	H5649_026_4	10			Select Care Drugs	4	01	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																														
H5649	027	0	1	01	01	H5649_027_0	10			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	10			Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5649	027	0	1	01	01	H5649_027_0	10			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	25	25	25				25	25	25				25		25
H5649	027	0	1	01	01	H5649_027_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	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	35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H5649	027	0	1	01	01	H5649_027_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				882.58	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	25						25						25		25
H5649	027	0	1	01	01	H5649_027_0	10			Select Care Drugs	4	01	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	10			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	10			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	10			Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				26.04	15	15	15																		15	15	15															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		35.00	15	15	15				15	15	15				15		15
H5649	028	0	1	01	01	H5649_028_0	10			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				67.88	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		35.00	25	25	25				25	25	25				25		25
H5649	028	0	1	01	01	H5649_028_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				530.80	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	25						25						25		25
H5649	028	0	1	01	01	H5649_028_0	10			Select Care Drugs	4	01	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	11			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	11			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	11			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	25	25	25				25	25	25				25		25
H5649	029	0	1	01	01	H5649_029_0	11			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	35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H5649	029	0	1	01	01	H5649_029_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				334.43	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5649	029	0	1	01	01	H5649_029_0	11			Select Care Drugs	4	01	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	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	001	0	1	02	01	H5652_001_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	001	0	1	02	01	H5652_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5652	001	0	1	02	01	H5652_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5652	001	0	1	02	01	H5652_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				436.00	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	25						25			25			25		25
H5652	003	0	1	02	01	H5652_003_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	003	0	1	02	01	H5652_003_0	4			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																														
H5652	003	0	1	02	01	H5652_003_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				30.00	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	25		25						25				25		25
H5652	003	0	1	02	01	H5652_003_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				73.00	44																				44																	44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5652	003	0	1	02	01	H5652_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				468.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5652	004	0	1	02	01	H5652_004_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	004	0	1	02	01	H5652_004_0	4			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		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	004	0	1	02	01	H5652_004_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				55.00	24		24																										24						24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	24		24						24			24	24		24
H5652	004	0	1	02	01	H5652_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	44																										44						44					44			44								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5652	004	0	1	02	01	H5652_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				451.00	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	25						25			25			25		25
H5652	006	0	1	02	01	H5652_006_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	006	0	1	02	01	H5652_006_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	006	0	1	02	01	H5652_006_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				31.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H5652	006	0	1	02	01	H5652_006_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				91.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5652	006	0	1	02	01	H5652_006_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				422.00	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	25						25			25			25		25
H5652	008	0	1	02	01	H5652_008_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	008	0	1	02	01	H5652_008_0	5			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	15.00		45.00																											45.00						0.00				15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5652	008	0	1	02	01	H5652_008_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	19		19																										19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	19		19						19			19	19		19
H5652	008	0	1	02	01	H5652_008_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				74.00	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	25						25			25			25		25
H5652	008	0	1	02	01	H5652_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				424.00	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	25						25			25			25		25
H5692	001	0	1	01	01	H5692_001_0	6		N	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																														
H5692	001	0	1	01	01	H5692_001_0	6		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				2	2		60	100				30		31				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					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H5692	001	0	1	01	01	H5692_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				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					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H5692	001	0	1	01	01	H5692_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				2	2		60	100				30		31				61.25	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					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H5692	001	0	1	01	01	H5692_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				494.70	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5692	001	0	1	01	01	H5692_001_0	6		N	Select Care Drugs	4	11	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5718	001	0	1	04	01	H5718_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	0	0	0				0	0	0				0		0
H5718	001	0	1	04	01	H5718_001_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	0	0	0				0	0	0				0		0
H5718	001	0	1	04	01	H5718_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				33.00	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	19	19	19				19	19	19				19		19
H5718	001	0	1	04	01	H5718_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				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	25	25	25				25	25	25				25		25
H5718	001	0	1	04	01	H5718_001_0	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	25						25						25		25
H5718	002	0	1	04	01	H5718_002_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	0	0	0				0	0	0				0		0
H5718	002	0	1	04	01	H5718_002_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	25	25	25				25	25	25				25		25
H5718	002	0	1	04	01	H5718_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				39.00	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	21	21	21				21	21	21				21		21
H5718	002	0	1	04	01	H5718_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				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	25	25	25				25	25	25				25		25
H5718	002	0	1	04	01	H5718_002_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	25						25						25		25
H5718	003	0	1	04	01	H5718_003_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H5718	003	0	1	04	01	H5718_003_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H5718	003	0	1	04	01	H5718_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				33.00	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	19	19	19				19	19	19				19		19
H5718	003	0	1	04	01	H5718_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				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	25	25	25				25	25	25				25		25
H5718	003	0	1	04	01	H5718_003_0	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	25						25						25		25
H5718	004	0	1	04	01	H5718_004_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5718	004	0	1	04	01	H5718_004_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5718	004	0	1	04	01	H5718_004_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5718	004	0	1	04	01	H5718_004_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H5718	004	0	1	04	01	H5718_004_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5718	004	0	1	04	01	H5718_004_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5718	005	0	1	04	01	H5718_005_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5718	005	0	1	04	01	H5718_005_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5718	005	0	1	04	01	H5718_005_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H5718	005	0	1	04	01	H5718_005_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H5718	005	0	1	04	01	H5718_005_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5718	005	0	1	04	01	H5718_005_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5718	006	0	1	04	01	H5718_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H5718	006	0	1	04	01	H5718_006_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H5718	006	0	1	04	01	H5718_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H5718	006	0	1	04	01	H5718_006_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H5718	006	0	1	04	01	H5718_006_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5718	006	0	1	04	01	H5718_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5734	001	0	1	01	01	H5734_001_0	5		N	Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	100				2	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5734	001	0	1	01	01	H5734_001_0	5		N	Generic	4	01	1	1	2	1	111		01	100		1	30	60	90				2	2			90				30		31				11.98	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						105.00				35.00		35.00	25	25	25						25				25		25
H5734	001	0	1	01	01	H5734_001_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				86.68	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						105.00				35.00		35.00	25	25	25						25				25		25
H5734	001	0	1	01	01	H5734_001_0	5		N	Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				55.57	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						105.00				35.00		35.00	25	25	25						25				25		25
H5734	001	0	1	01	01	H5734_001_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				437.75	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5734	001	0	1	01	01	H5734_001_0	5		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 Brand, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H5774	022	0	1	01	01	H5774_022_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	022	0	1	01	01	H5774_022_0	5			Generic	4	01	3	2	2	1		110	01	100		1				30		90	1	2			90				30		31								8.00		16.00					0.00		0.00							0.00																8.00				0.00			0.27	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	022	0	1	01	01	H5774_022_0	5			Preferred Brand	4	10	3	2	3	1		110	01	100		1				30		90	1	2			90				30		31								20.00		40.00					0.00		0.00							0.00																20.00				0.00			0.67	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	022	0	1	01	01	H5774_022_0	5			Non-Preferred Brand	4	10	3	2	4	1		110	01	100		1				30		90	1	1			90				30		31								55.00		110.00					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		10.00	25		25	25		25			25				25		25
H5774	022	0	1	01	01	H5774_022_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31											33.00	33		33				33.00	33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	022	0	1	01	01	H5774_022_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	3.00		6.00	0.00		0.00			0.00				3.00		0.00	25		25	25		25			25				25		25
H5774	031	0	1	02	01	H5774_031_0	5			Preferred Generic	4	01	3	2	1	1		110	01	100		1				30		90	1	2			90				30		31								5.00		10.00					0.00		0.00							0.00																5.00				0.00			0.17	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	031	0	1	02	01	H5774_031_0	5			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	5			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	5			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	25		25	25		25			25				25		25
H5774	031	0	1	02	01	H5774_031_0	5			Specialty Tier	4	11	1	1	5	1		110	01	100		1				30		90	1	1			90				30		31												33		33					33		33						33															33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs																														
H5774	031	0	1	02	01	H5774_031_0	5			Select Care Drugs	4	11	1	2	6	1		110	01	100		1				30		90	1	2			90				30		31								3.00		6.00					0.00		0.00							0.00																3.00				0.00			0.10	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	3.00		6.00	0.00		0.00			0.00				3.00		0.00	25		25	25		25			25				25		25
H5774	038	0	1	01	01	H5774_038_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	038	0	1	01	01	H5774_038_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	038	0	1	01	01	H5774_038_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	038	0	1	01	01	H5774_038_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		35.00	25		25	25		25			25				25		25
H5774	038	0	1	01	01	H5774_038_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	038	0	1	01	01	H5774_038_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	25		25	25		25			25				25		25
H5774	046	0	1	01	01	H5774_046_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	046	0	1	01	01	H5774_046_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	046	0	1	01	01	H5774_046_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	046	0	1	01	01	H5774_046_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	25		25	25		25			25				25		25
H5774	046	0	1	01	01	H5774_046_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	046	0	1	01	01	H5774_046_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	25		25	25		25			25				25		25
H5774	047	1	1	01	01	H5774_047_1	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	047	1	1	01	01	H5774_047_1	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	047	1	1	01	01	H5774_047_1	6			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	047	1	1	01	01	H5774_047_1	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					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		35.00	25		25	25		25			25				25		25
H5774	047	1	1	01	01	H5774_047_1	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	047	1	1	01	01	H5774_047_1	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	25		25	25		25			25				25		25
H5774	047	2	1	01	01	H5774_047_2	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	047	2	1	01	01	H5774_047_2	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	047	2	1	01	01	H5774_047_2	6			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	047	2	1	01	01	H5774_047_2	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					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		35.00	25		25	25		25			25				25		25
H5774	047	2	1	01	01	H5774_047_2	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	047	2	1	01	01	H5774_047_2	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	25		25	25		25			25				25		25
H5774	047	3	1	01	01	H5774_047_3	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	047	3	1	01	01	H5774_047_3	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	047	3	1	01	01	H5774_047_3	6			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	047	3	1	01	01	H5774_047_3	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					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		35.00	25		25	25		25			25				25		25
H5774	047	3	1	01	01	H5774_047_3	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	047	3	1	01	01	H5774_047_3	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	25		25	25		25			25				25		25
H5774	047	4	1	01	01	H5774_047_4	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	047	4	1	01	01	H5774_047_4	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	047	4	1	01	01	H5774_047_4	6			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	047	4	1	01	01	H5774_047_4	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					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		35.00	25		25	25		25			25				25		25
H5774	047	4	1	01	01	H5774_047_4	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	047	4	1	01	01	H5774_047_4	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	25		25	25		25			25				25		25
H5774	047	5	1	01	01	H5774_047_5	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	047	5	1	01	01	H5774_047_5	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	047	5	1	01	01	H5774_047_5	6			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	047	5	1	01	01	H5774_047_5	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					10.00		20.00							20.00																55.00				10.00			1.83	0.33				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		70.00	10.00		20.00			20.00				35.00		35.00	25		25	25		25			25				25		25
H5774	047	5	1	01	01	H5774_047_5	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	047	5	1	01	01	H5774_047_5	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	25		25	25		25			25				25		25
H5779	002	0	1	01	01	H5779_002_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5779	002	0	1	01	01	H5779_002_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5779	002	0	1	01	01	H5779_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											126.17	25	25	25				126.17	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	002	0	1	01	01	H5779_002_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.21	35	35	35				72.09	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	002	0	1	01	01	H5779_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	002	0	1	01	01	H5779_002_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	007	0	1	01	01	H5779_007_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5779	007	0	1	01	01	H5779_007_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5779	007	0	1	01	01	H5779_007_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.14	25	25	25				112.14	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	007	0	1	01	01	H5779_007_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											99.28	47	47	47				99.28	47	47	47											47	47					47	47			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	007	0	1	01	01	H5779_007_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	007	0	1	01	01	H5779_007_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5779	009	0	1	01	01	H5779_009_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5779	009	0	1	01	01	H5779_009_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.24	25	25	25				123.24	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	009	0	1	01	01	H5779_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											69.33	33	33	33				67.23	32	32	32											33	33					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	009	0	1	01	01	H5779_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	009	0	1	01	01	H5779_009_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	010	0	1	01	01	H5779_010_0	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5779	010	0	1	01	01	H5779_010_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5779	010	0	1	01	01	H5779_010_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.77	25	25	25				120.77	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	010	0	1	01	01	H5779_010_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											79.29	47	47	47				77.60	46	46	46											47	47					46	46			47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5779	010	0	1	01	01	H5779_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5779	010	0	1	01	01	H5779_010_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											69.94	24	24	24				96.98	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5793	001	0	1	02	01	H5793_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											42.45	25	25	25				48.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	001	0	1	02	01	H5793_001_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											530.98	25						620.62	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	25			25			25			25			25		25
H5793	010	0	1	02	01	H5793_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																														
H5793	010	0	1	02	01	H5793_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																														
H5793	010	0	1	02	01	H5793_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											63.10	24	24	24				95.03	24	24	24										24	24	24				24	24	24				24		24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5793	010	0	1	02	01	H5793_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											44.03	25	25	25				51.66	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	010	0	1	02	01	H5793_010_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											494.80	25						651.47	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	25			25			25			25			25		25
H5793	014	0	1	02	01	H5793_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																														
H5793	014	0	1	02	01	H5793_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																														
H5793	014	0	1	02	01	H5793_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											71.64	24	24	24				97.39	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5793	014	0	1	02	01	H5793_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											36.00	25	25	25				47.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	014	0	1	02	01	H5793_014_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											553.93	25						568.01	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	25			25			25			25			25		25
H5793	015	0	1	02	01	H5793_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																														
H5793	015	0	1	02	01	H5793_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																														
H5793	015	0	1	02	01	H5793_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											64.61	22	22	22				87.45	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	22	22	22	22	22	22	22	22	22	22	22	22	22		22
H5793	015	0	1	02	01	H5793_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											39.87	25	25	25				45.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	015	0	1	02	01	H5793_015_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											588.42	27						668.99	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	25			25			25			25			25		25
H5793	017	0	1	02	01	H5793_017_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5793	017	0	1	02	01	H5793_017_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5793	017	0	1	02	01	H5793_017_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				73.37	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	22	22	22				22	22	22				22		22
H5793	017	0	1	02	01	H5793_017_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.40	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		35.00	25	25	25				25	25	25				25		25
H5793	017	0	1	02	01	H5793_017_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				463.18	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5793	018	0	1	02	01	H5793_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																														
H5793	018	0	1	02	01	H5793_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																														
H5793	018	0	1	02	01	H5793_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											70.60	24	24	24				95.86	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H5793	018	0	1	02	01	H5793_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											38.53	25	25	25				50.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	018	0	1	02	01	H5793_018_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											522.40	25						587.51	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	25			25			25			25			25		25
H5793	019	0	1	02	01	H5793_019_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	019	0	1	02	01	H5793_019_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											68.66	25	25	25				88.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	019	0	1	02	01	H5793_019_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											41.87	30	30	30				46.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5793	019	0	1	02	01	H5793_019_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											621.05	30						764.15	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	25			25			25			25			25		25
H5793	020	0	1	02	01	H5793_020_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5793	020	0	1	02	01	H5793_020_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5793	020	0	1	02	01	H5793_020_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				76.12	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	22	22	22				22	22	22				22		22
H5793	020	0	1	02	01	H5793_020_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				42.43	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5793	020	0	1	02	01	H5793_020_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				452.67	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5810	014	0	1	01	01	H5810_014_0	8			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	6.00																			3.00	6.00	6.00																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5810	014	0	1	01	01	H5810_014_0	8			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	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	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	25	25	25				25	25	25				25		25
H5810	014	0	1	01	01	H5810_014_0	8			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.04	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		35.00	25	25	25				25	25	25				25		25
H5810	014	0	1	01	01	H5810_014_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				548.55	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	25						25						25		25
H5810	014	0	1	01	01	H5810_014_0	8			Select Care Drugs	4	01	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																														
H5823	010	0	1	01	01	H5823_010_0	8		N	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																														
H5823	010	0	1	01	01	H5823_010_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5823	010	0	1	01	01	H5823_010_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				32.01	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		35.00	20	20	20				20	20	20				20		20
H5823	010	0	1	01	01	H5823_010_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				68.64	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		35.00	25	25	25				25	25	25				25		25
H5823	010	0	1	01	01	H5823_010_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				753.25	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	25						25						25		25
H5823	010	0	1	01	01	H5823_010_0	8		N	Select Care Drugs	4	01	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																														
H5823	013	1	1	01	01	H5823_013_1	8		N	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																														
H5823	013	1	1	01	01	H5823_013_1	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.22	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5823	013	1	1	01	01	H5823_013_1	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.61	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	20	20	20				20	20	20				20		20
H5823	013	1	1	01	01	H5823_013_1	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.37	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		35.00	25	25	25				25	25	25				25		25
H5823	013	1	1	01	01	H5823_013_1	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				479.31	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	25						25						25		25
H5823	013	1	1	01	01	H5823_013_1	8		N	Select Care Drugs	4	01	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																														
H5823	013	2	1	01	01	H5823_013_2	8		N	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																														
H5823	013	2	1	01	01	H5823_013_2	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.22	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5823	013	2	1	01	01	H5823_013_2	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				28.61	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	20	20	20				20	20	20				20		20
H5823	013	2	1	01	01	H5823_013_2	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.37	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		35.00	25	25	25				25	25	25				25		25
H5823	013	2	1	01	01	H5823_013_2	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				479.31	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	25						25						25		25
H5823	013	2	1	01	01	H5823_013_2	8		N	Select Care Drugs	4	01	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	014	0	1	01	01	H5826_014_0	5		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				7.91	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	014	0	1	01	01	H5826_014_0	5		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				10.63	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	014	0	1	01	01	H5826_014_0	5		N	Preferred Brand	4	11	1	1	3	1	010		01	010		1	30								30						30		31				63.04	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	25						25						25		25
H5826	014	0	1	01	01	H5826_014_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				77.35	45																				45																	45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5826	014	0	1	01	01	H5826_014_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				497.81	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	014	0	1	01	01	H5826_014_0	5		N	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																														
H5826	017	0	1	01	01	H5826_017_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				8.12	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	017	0	1	01	01	H5826_017_0	6		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				11.51	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	017	0	1	01	01	H5826_017_0	6		N	Preferred Brand	4	11	1	1	3	1	010		01	010		1	30								30						30		31				66.62	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	25						25						25		25
H5826	017	0	1	01	01	H5826_017_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30								30						30		31				83.02	50																				50																	50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5826	017	0	1	01	01	H5826_017_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				481.74	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5826	017	0	1	01	01	H5826_017_0	6		N	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																														
H5828	001	0	1	01	01	H5828_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H5828	001	0	1	01	01	H5828_001_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	001	0	1	01	01	H5828_001_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	001	0	1	01	01	H5828_001_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				24.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	001	0	1	01	01	H5828_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	001	0	1	01	01	H5828_001_0	6		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																														
H5828	002	0	1	01	01	H5828_002_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	002	0	1	01	01	H5828_002_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	002	0	1	01	01	H5828_002_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				73.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	002	0	1	01	01	H5828_002_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				24.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	002	0	1	01	01	H5828_002_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	002	0	1	01	01	H5828_002_0	6		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																														
H5828	008	0	1	02	01	H5828_008_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																														
H5828	008	0	1	02	01	H5828_008_0	5			Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	008	0	1	02	01	H5828_008_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				70.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	008	0	1	02	01	H5828_008_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				22.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	008	0	1	02	01	H5828_008_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	008	0	1	02	01	H5828_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		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																														
H5828	013	0	1	02	01	H5828_013_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																														
H5828	013	0	1	02	01	H5828_013_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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	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	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.00	25	25	25				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	70.00	105.00	35.00	70.00	105.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5828	013	0	1	02	01	H5828_013_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											22.00	30	30	30				16.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5828	013	0	1	02	01	H5828_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	013	0	1	02	01	H5828_013_0	6			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	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																														
H5828	014	0	1	02	01	H5828_014_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	014	0	1	02	01	H5828_014_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											77.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5828	014	0	1	02	01	H5828_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											15.00	30	30	30				12.00	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	25	25	25	25	25	25	25	25	25				25		25
H5828	014	0	1	02	01	H5828_014_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	015	0	1	02	01	H5828_015_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																														
H5828	015	0	1	02	01	H5828_015_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	015	0	1	02	01	H5828_015_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.00	25	25	25				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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H5828	015	0	1	02	01	H5828_015_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											15.00	30	30	30				12.00	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	25	25	25	25	25	25	25	25	25				25		25
H5828	015	0	1	02	01	H5828_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	016	0	1	02	01	H5828_016_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																														
H5828	016	0	1	02	01	H5828_016_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	016	0	1	02	01	H5828_016_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											75.00	25	25	25				99.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H5828	016	0	1	02	01	H5828_016_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											14.00	30	30	30				11.00	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	25	25	25	25	25	25	25	25	25				25		25
H5828	016	0	1	02	01	H5828_016_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	017	0	1	02	01	H5828_017_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																														
H5828	017	0	1	02	01	H5828_017_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	017	0	1	02	01	H5828_017_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.00	25	25	25				108.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
H5828	017	0	1	02	01	H5828_017_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											15.00	30	30	30				12.00	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	25	25	25	25	25	25	25	25	25				25		25
H5828	017	0	1	02	01	H5828_017_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5828	018	0	1	01	01	H5828_018_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	018	0	1	01	01	H5828_018_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	018	0	1	01	01	H5828_018_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				73.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	018	0	1	01	01	H5828_018_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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5828	018	0	1	01	01	H5828_018_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34				12.49	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5828	018	0	1	01	01	H5828_018_0	6		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																														
H5843	001	0	1	01	01	H5843_001_0	7			Preferred Generic	4	01	1	2	1	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	0		0				0		0				0		0
H5843	001	0	1	01	01	H5843_001_0	7			Generic	4	01	1	2	2	1	110		01	110		1	31		90				1	2	31		90				31		31	5.00		15.00																			5.00		10.00																5.00				5.00		0.16			0.16			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				5.00		10.00				5.00		5.00	25		25				25		25				25		25
H5843	001	0	1	01	01	H5843_001_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																			47.00		94.00																47.00				47.00		1.52			1.52			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H5843	001	0	1	01	01	H5843_001_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				86.47	50		50																		50		50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
H5843	001	0	1	01	01	H5843_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				390.07	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5852	001	0	1	01	01	H5852_001_0	6			Generic	3	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	15		15										15		15
H5852	001	0	1	01	01	H5852_001_0	6			Preferred Brand	3	10	1	1	2	1	110		01			1	30		100				1	2							30		34				92.00	22		22																																			22			22								Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00		105.00										35.00		35.00	22		22										22		22
H5852	001	0	1	01	01	H5852_001_0	6			Non-Preferred Brand	3	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	3	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	25		25										25		25
H5852	001	0	1	01	01	H5852_001_0	6			Select Care Drugs	3	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	012	0	1	02	01	H5854_012_0	4			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	4			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	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											54.00	25	25	25				90.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H5854	012	0	1	02	01	H5854_012_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											38.00	25	25	25				28.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H5854	012	0	1	02	01	H5854_012_0	4			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	4			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	013	0	1	01	01	H5854_013_0	5		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																														
H5854	013	0	1	01	01	H5854_013_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	013	0	1	01	01	H5854_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		34				84.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5854	013	0	1	01	01	H5854_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5854	013	0	1	01	01	H5854_013_0	5		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																														
H5854	013	0	1	01	01	H5854_013_0	5		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																														
H5854	019	1	1	01	01	H5854_019_1	4			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	019	1	1	01	01	H5854_019_1	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	019	1	1	01	01	H5854_019_1	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.00	25	25	25				89.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H5854	019	1	1	01	01	H5854_019_1	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											34.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5854	019	1	1	01	01	H5854_019_1	4			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																														
H5854	019	1	1	01	01	H5854_019_1	4			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	019	2	1	01	01	H5854_019_2	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	019	2	1	01	01	H5854_019_2	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	019	2	1	01	01	H5854_019_2	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											53.00	25	25	25				89.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H5854	019	2	1	01	01	H5854_019_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											34.00	30	30	30				22.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H5854	019	2	1	01	01	H5854_019_2	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	019	2	1	01	01	H5854_019_2	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																														
H5854	020	0	1	01	01	H5854_020_0	5		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																														
H5854	020	0	1	01	01	H5854_020_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5854	020	0	1	01	01	H5854_020_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				88.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5854	020	0	1	01	01	H5854_020_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		34				28.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5854	020	0	1	01	01	H5854_020_0	5		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																														
H5854	020	0	1	01	01	H5854_020_0	5		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																														
H5859	001	0	1	01	01	H5859_001_0	9		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.09	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5859	001	0	1	01	01	H5859_001_0	9		N	Generic	4	01	3	1	2	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				10.55	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5859	001	0	1	01	01	H5859_001_0	9		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				121.56	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	25	25	25				25	25	25				25		25
H5859	001	0	1	01	01	H5859_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				24.13	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5859	001	0	1	01	01	H5859_001_0	9		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				665.51	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5859	001	0	1	01	01	H5859_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		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care 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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
H5883	003	1	1	02	01	H5883_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																														
H5883	003	1	1	02	01	H5883_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																														
H5883	003	1	1	02	01	H5883_003_1	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
H5883	003	1	1	02	01	H5883_003_1	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
H5883	003	1	1	02	01	H5883_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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											44.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											44.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											44.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				17.00	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	20		20	20		20	20		20	20		20	20		20
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											44.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
H5883	007	0	1	01	01	H5883_007_0	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	007	0	1	01	01	H5883_007_0	8			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								7.00		21.00					2.00		0.00											7.00		21.00				2.00		0.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5883	007	0	1	01	01	H5883_007_0	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											26.00	20		20				25.00	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	20		20	20		20	20		20	20		20	20		20
H5883	007	0	1	01	01	H5883_007_0	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H5883	007	0	1	01	01	H5883_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5883	014	1	1	02	01	H5883_014_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	014	1	1	02	01	H5883_014_1	7			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																														
H5883	014	1	1	02	01	H5883_014_1	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											28.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H5883	014	1	1	02	01	H5883_014_1	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				54.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5883	014	1	1	02	01	H5883_014_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5883	014	2	1	02	01	H5883_014_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	014	2	1	02	01	H5883_014_2	7			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																														
H5883	014	2	1	02	01	H5883_014_2	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											28.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H5883	014	2	1	02	01	H5883_014_2	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				54.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5883	014	2	1	02	01	H5883_014_2	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5883	014	4	1	02	01	H5883_014_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	014	4	1	02	01	H5883_014_4	7			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																														
H5883	014	4	1	02	01	H5883_014_4	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											28.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H5883	014	4	1	02	01	H5883_014_4	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				54.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5883	014	4	1	02	01	H5883_014_4	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5883	014	5	1	02	01	H5883_014_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	014	5	1	02	01	H5883_014_5	7			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																														
H5883	014	5	1	02	01	H5883_014_5	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											28.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H5883	014	5	1	02	01	H5883_014_5	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				54.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H5883	014	5	1	02	01	H5883_014_5	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H5900	001	0	1	04	01	H5900_001_0	5			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	5			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	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5900	001	0	1	04	01	H5900_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				47.55	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	20	20	20				20	20	20				20		20
H5900	001	0	1	04	01	H5900_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				60.33	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	25	25	25				25	25	25				25		25
H5900	001	0	1	04	01	H5900_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1042.67	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5900	004	0	1	04	01	H5900_004_0	6			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5900	004	0	1	04	01	H5900_004_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	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5900	004	0	1	04	01	H5900_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				51.53	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	20	20	20				20	20	20				20		20
H5900	004	0	1	04	01	H5900_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				58.89	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5900	004	0	1	04	01	H5900_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1016.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5900	008	0	1	04	01	H5900_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	0.00	0.00	0.00																			0.00	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	008	0	1	04	01	H5900_008_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	12.50																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5900	008	0	1	04	01	H5900_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				52.60	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	20	20	20				20	20	20				20		20
H5900	008	0	1	04	01	H5900_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				57.34	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	25	25	25				25	25	25				25		25
H5900	008	0	1	04	01	H5900_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1012.51	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H5926	001	0	1	01	01	H5926_001_0	8		N	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																														
H5926	001	0	1	01	01	H5926_001_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5926	001	0	1	01	01	H5926_001_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				32.79	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	20	20	20				20	20	20				20		20
H5926	001	0	1	01	01	H5926_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.91	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		35.00	25	25	25				25	25	25				25		25
H5926	001	0	1	01	01	H5926_001_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				472.37	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	25						25						25		25
H5926	001	0	1	01	01	H5926_001_0	8		N	Select Care Drugs	4	01	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																														
H5926	008	0	1	01	01	H5926_008_0	9		N	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																														
H5926	008	0	1	01	01	H5926_008_0	9		N	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																														
H5926	008	0	1	01	01	H5926_008_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				25.61	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	20	20	20				20	20	20				20		20
H5926	008	0	1	01	01	H5926_008_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				56.15	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		35.00	25	25	25				25	25	25				25		25
H5926	008	0	1	01	01	H5926_008_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				516.53	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	25						25						25		25
H5926	008	0	1	01	01	H5926_008_0	9		N	Select Care Drugs	4	01	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																														
H5926	009	0	1	01	01	H5926_009_0	9		N	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																														
H5926	009	0	1	01	01	H5926_009_0	9		N	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																														
H5926	009	0	1	01	01	H5926_009_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				35.65	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		35.00	20	20	20				20	20	20				20		20
H5926	009	0	1	01	01	H5926_009_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				64.26	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		35.00	25	25	25				25	25	25				25		25
H5926	009	0	1	01	01	H5926_009_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				517.31	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5926	009	0	1	01	01	H5926_009_0	9		N	Select Care Drugs	4	01	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																														
H5928	004	0	1	01	01	H5928_004_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																														
H5928	004	0	1	01	01	H5928_004_0	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											53.40	20	20	20				51.34	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H5928	004	0	1	01	01	H5928_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											100.13	25	25	25				68.25	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H5928	004	0	1	01	01	H5928_004_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											551.97	28						515.74	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5928	010	0	1	01	01	H5928_010_0	6			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	6			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	6			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	100	2	2			100				30		31											54.15	20	20	20				55.66	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			105.00				35.00		35.00	20	20	20	20	20	20			20				20		20
H5928	010	0	1	01	01	H5928_010_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	100	2	2			100				30		31											104.82	25	25	25				78.74	25	25	25						25															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	25	25	25	25	25	25			25				25		25
H5928	010	0	1	01	01	H5928_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											657.84	28						533.88	28						28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5938	001	0	1	01	01	H5938_001_0	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	001	0	1	01	01	H5938_001_0	8			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	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5938	001	0	1	01	01	H5938_001_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H5938	001	0	1	01	01	H5938_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				578.77	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	8			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	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	006	0	1	01	01	H5938_006_0	8			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	8			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	45.00	90.00	135.00																			45.00	90.00	112.50																45.00				45.00		1.50			1.50			1.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	87.50				35.00		35.00	25	25	25				25	25	25				25		25
H5938	006	0	1	01	01	H5938_006_0	8			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	95.00	190.00	285.00																			95.00	190.00	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	25	25	25				25	25	25				25		25
H5938	006	0	1	01	01	H5938_006_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				675.48	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	8			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	8			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	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	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, Select Care Drugs																														
H5938	008	0	1	01	01	H5938_008_0	8			Preferred Brand	4	11	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25				25		25
H5938	008	0	1	01	01	H5938_008_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					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	25	25	25	25	25	25	25	25	25				25		25
H5938	008	0	1	01	01	H5938_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											540.27	30						100.00	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	008	0	1	01	01	H5938_008_0	8			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	009	0	1	01	01	H5938_009_0	8			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	009	0	1	01	01	H5938_009_0	8			Generic	4	01	1	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								14.00	28.00	42.00					0.00	0.00	0.00					7.00	14.00	17.50																14.00				14.00			0.47	0.00	0.23			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	009	0	1	01	01	H5938_009_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	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	25	25	25	25	25	25	25	25	25				25		25
H5938	009	0	1	01	01	H5938_009_0	8			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								100.00	200.00	300.00					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	25	25	25	25	25	25	25	25	25				25		25
H5938	009	0	1	01	01	H5938_009_0	8			Specialty Tier	4	11	1	1	5	1		010	01	000		1				30											30		31											656.63	30						100.00	30																							30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5938	009	0	1	01	01	H5938_009_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5943	003	0	1	02	01	H5943_003_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	003	0	1	02	01	H5943_003_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	003	0	1	02	01	H5943_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											96.52	25	25	25				96.52	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5943	003	0	1	02	01	H5943_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											37.03	25	25	25				37.03	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5943	003	0	1	02	01	H5943_003_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	004	0	1	02	01	H5943_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								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	004	0	1	02	01	H5943_004_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					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	004	0	1	02	01	H5943_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											94.73	25	25	25				94.73	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5943	004	0	1	02	01	H5943_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											35.58	25	25	25				35.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H5943	004	0	1	02	01	H5943_004_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5945	001	0	1	01	01	H5945_001_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	001	0	1	01	01	H5945_001_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	12.00	24.00	24.00						24.00				12.00		12.00	25	25	25						25				25		25
H5945	001	0	1	01	01	H5945_001_0	6			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	25	25	25						25				25		25
H5945	001	0	1	01	01	H5945_001_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	001	0	1	01	01	H5945_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				107.38	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	001	0	1	01	01	H5945_001_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	002	0	1	01	01	H5945_002_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	002	0	1	01	01	H5945_002_0	7			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	25	25	25						25				25		25
H5945	002	0	1	01	01	H5945_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	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	25	25	25						25				25		25
H5945	002	0	1	01	01	H5945_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	002	0	1	01	01	H5945_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				119.62	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	002	0	1	01	01	H5945_002_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	013	0	1	01	01	H5945_013_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	013	0	1	01	01	H5945_013_0	6			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	25	25	25						25				25		25
H5945	013	0	1	01	01	H5945_013_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				96.69	25	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	25	25	25						25				25		25
H5945	013	0	1	01	01	H5945_013_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				59.13	47	47	47																				47															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	013	0	1	01	01	H5945_013_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				154.25	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	013	0	1	01	01	H5945_013_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	014	0	1	01	01	H5945_014_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	014	0	1	01	01	H5945_014_0	6			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	25	25	25						25				25		25
H5945	014	0	1	01	01	H5945_014_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				98.08	25	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	25	25	25						25				25		25
H5945	014	0	1	01	01	H5945_014_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				58.54	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	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				166.58	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	014	0	1	01	01	H5945_014_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	016	0	1	01	01	H5945_016_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	016	0	1	01	01	H5945_016_0	6			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	25	25	25						25				25		25
H5945	016	0	1	01	01	H5945_016_0	6			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	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	25	25	25						25				25		25
H5945	016	0	1	01	01	H5945_016_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	016	0	1	01	01	H5945_016_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				119.60	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	016	0	1	01	01	H5945_016_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	017	0	1	01	01	H5945_017_0	6		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	6		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	25	25	25						25				25		25
H5945	017	0	1	01	01	H5945_017_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				98.26	25	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	25	25	25						25				25		25
H5945	017	0	1	01	01	H5945_017_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				63.20	48	48	48																				48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	017	0	1	01	01	H5945_017_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				150.38	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	017	0	1	01	01	H5945_017_0	6		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	7		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	7		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	25	25	25						25				25		25
H5945	018	0	1	01	01	H5945_018_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				92.27	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	24	24	24						24				24		24
H5945	018	0	1	01	01	H5945_018_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				62.90	48	48	48																				48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	018	0	1	01	01	H5945_018_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				170.99	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	018	0	1	01	01	H5945_018_0	7		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	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	027	0	1	01	01	H5945_027_0	6			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	25	25	25						25				25		25
H5945	027	0	1	01	01	H5945_027_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				106.76	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	23	23	23						23				23		23
H5945	027	0	1	01	01	H5945_027_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				52.19	45	45	45																				45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5945	027	0	1	01	01	H5945_027_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				157.00	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5945	027	0	1	01	01	H5945_027_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5959	009	0	1	04	01	H5959_009_0	4			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	009	0	1	04	01	H5959_009_0	4			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	009	0	1	04	01	H5959_009_0	4			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				57.48	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	009	0	1	04	01	H5959_009_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				94.27	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	009	0	1	04	01	H5959_009_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	010	1	1	04	01	H5959_010_1	3			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	1	1	04	01	H5959_010_1	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	1	1	04	01	H5959_010_1	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				56.42	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	1	1	04	01	H5959_010_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				98.99	42	42	42																								50	50	50				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	25	25	25				25	25	25	25	25	25	25		25
H5959	010	1	1	04	01	H5959_010_1	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5959	010	2	1	04	01	H5959_010_2	3			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	2	1	04	01	H5959_010_2	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	2	1	04	01	H5959_010_2	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				56.42	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	010	2	1	04	01	H5959_010_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				98.99	42	42	42																								50	50	50				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	25	25	25				25	25	25	25	25	25	25		25
H5959	010	2	1	04	01	H5959_010_2	3			Specialty Tier	4	11	1	1	5	1	010		01		010	1	31											31			31		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5959	011	0	1	04	01	H5959_011_0	5			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	011	0	1	04	01	H5959_011_0	5			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	011	0	1	04	01	H5959_011_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				55.85	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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				97.73	45	45	45																								50	50	50				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	25	25	25				25	25	25	25	25	25	25		25
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					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5959	012	0	1	04	01	H5959_012_0	4			Preferred Generic	4	11	3	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	012	0	1	04	01	H5959_012_0	4			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	012	0	1	04	01	H5959_012_0	4			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				46.25	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	012	0	1	04	01	H5959_012_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				67.60	43	43	43																								45	45	45				43	43	43			43			43								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	25	25	25				25	25	25	25	25	25	25		25
H5959	012	0	1	04	01	H5959_012_0	4			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																														
H5959	013	1	1	04	01	H5959_013_1	3			Preferred Generic	4	11	3	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	013	1	1	04	01	H5959_013_1	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
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				45.38	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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				69.14	43	43	43																								45	45	45				43	43	43			43			43								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	25	25	25				25	25	25	25	25	25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5959	013	2	1	04	01	H5959_013_2	3			Preferred Generic	4	11	3	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	013	2	1	04	01	H5959_013_2	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
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				45.38	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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				69.14	43	43	43																								45	45	45				43	43	43			43			43								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	25	25	25				25	25	25	25	25	25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H5959	014	1	1	04	01	H5959_014_1	3			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	1	1	04	01	H5959_014_1	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	1	1	04	01	H5959_014_1	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				60.55	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	1	1	04	01	H5959_014_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				99.14	44	44	44																								50	50	50				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	25	25	25				25	25	25	25	25	25	25		25
H5959	014	1	1	04	01	H5959_014_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	014	2	1	04	01	H5959_014_2	3			Preferred Generic	4	11	1	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	2	1	04	01	H5959_014_2	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	2	1	04	01	H5959_014_2	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				60.55	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	014	2	1	04	01	H5959_014_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				99.14	44	44	44																								50	50	50				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	25	25	25				25	25	25	25	25	25	25		25
H5959	014	2	1	04	01	H5959_014_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	015	0	1	04	01	H5959_015_0	3			Preferred Generic	4	11	3	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	015	0	1	04	01	H5959_015_0	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	015	0	1	04	01	H5959_015_0	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				48.39	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	015	0	1	04	01	H5959_015_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				72.89	43	43	43																								45	45	45				43	43	43			43			43								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	25	25	25				25	25	25	25	25	25	25		25
H5959	015	0	1	04	01	H5959_015_0	3			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																														
H5959	016	0	1	04	01	H5959_016_0	3			Preferred Generic	4	11	3	2	1	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	016	0	1	04	01	H5959_016_0	3			Generic	4	11	1	2	2	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31	0.00	0.00	0.00																									10.00	20.00	20.00				0.00	0.00	0.00				0.00				0.00		0.00				0.32	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				10.00	20.00	20.00	0.00	0.00	0.00	0.00		0.00	25	25	25				25	25	25	25	25	25	25		25
H5959	016	0	1	04	01	H5959_016_0	3			Preferred Brand	4	11	1	1	3	1	111		01		111	1	31	60	90				1	2				31	60	90	31		31				48.51	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	70.00				35.00	70.00	70.00	35.00	70.00	70.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H5959	016	0	1	04	01	H5959_016_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				58.79	43	43	43																								45	45	45				43	43	43			43			43								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	25	25	25				25	25	25	25	25	25	25		25
H5959	016	0	1	04	01	H5959_016_0	3			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																														
H5965	004	0	1	04	01	H5965_004_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	004	0	1	04	01	H5965_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	004	0	1	04	01	H5965_004_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.68	20	20	20				82.68	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H5965	004	0	1	04	01	H5965_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5965	004	0	1	04	01	H5965_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	004	0	1	04	01	H5965_004_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	006	0	1	04	01	H5965_006_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	006	0	1	04	01	H5965_006_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	006	0	1	04	01	H5965_006_0	8		N	Preferred Brand	3	11	1	2	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00												94.00	141.00					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	105.00		70.00	105.00		70.00	94.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5965	006	0	1	04	01	H5965_006_0	8		N	Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.46	44	44	44				77.46	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5965	006	0	1	04	01	H5965_006_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	006	0	1	04	01	H5965_006_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								1.00	2.00	3.00					0.00	0.00	0.00												2.00	3.00					0.00	0.00				1.00				1.00			0.03	0.00				0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	008	0	1	04	01	H5965_008_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H5965	008	0	1	04	01	H5965_008_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H5965	008	0	1	04	01	H5965_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											113.22	25	25	25				113.22	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5965	008	0	1	04	01	H5965_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											68.54	36	36	36				66.63	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H5965	008	0	1	04	01	H5965_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5965	008	0	1	04	01	H5965_008_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	002	0	1	01	01	H5969_002_0	5		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.18	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	002	0	1	01	01	H5969_002_0	5		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				5.94	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	002	0	1	01	01	H5969_002_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				71.11	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	25	25	25				25	25	25				25		25
H5969	002	0	1	01	01	H5969_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				61.10	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	25	25	25				25	25	25				25		25
H5969	002	0	1	01	01	H5969_002_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				479.67	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5969	002	0	1	01	01	H5969_002_0	5		N	Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	003	0	1	01	01	H5969_003_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.72	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	003	0	1	01	01	H5969_003_0	6		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				6.27	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5969	003	0	1	01	01	H5969_003_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				74.41	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H5969	003	0	1	01	01	H5969_003_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				52.16	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	25	25	25				25	25	25				25		25
H5969	003	0	1	01	01	H5969_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				486.18	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H5969	003	0	1	01	01	H5969_003_0	6		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																														
H5970	028	0	1	04	01	H5970_028_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	0		0				25		25	0		0	0		0
H5970	028	0	1	04	01	H5970_028_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5970	028	0	1	04	01	H5970_028_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	25		25				25		25	25		25	25		25
H5970	028	0	1	04	01	H5970_028_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				94.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H5970	029	0	1	04	01	H5970_029_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	0		0				25		25	0		0	0		0
H5970	029	0	1	04	01	H5970_029_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H5970	029	0	1	04	01	H5970_029_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	25		25				25		25	25		25	25		25
H5970	029	0	1	04	01	H5970_029_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H5970	029	0	1	04	01	H5970_029_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	25						25			25			25		25
H5970	030	0	1	04	01	H5970_030_0	2			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	0		0				25		25	0		0	0		0
H5970	030	0	1	04	01	H5970_030_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5970	030	0	1	04	01	H5970_030_0	2			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	33.00		99.00																									47.00		141.00				33.00		66.00				33.00				33.00		1.10				1.57	1.10	1.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	33.00		99.00				35.00		105.00	33.00		66.00	33.00		33.00	25		25				25		25	25		25	25		25
H5970	030	0	1	04	01	H5970_030_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
H5970	030	0	1	04	01	H5970_030_0	2			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	25						25			25			25		25
H5970	031	0	1	04	01	H5970_031_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	0		0				25		25	0		0	0		0
H5970	031	0	1	04	01	H5970_031_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5970	031	0	1	04	01	H5970_031_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	25		25				25		25	25		25	25		25
H5970	031	0	1	04	01	H5970_031_0	3			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																								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	25		25				25		25	25		25	25		25
H5970	031	0	1	04	01	H5970_031_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	25						25			25			25		25
H5970	032	0	1	04	01	H5970_032_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	0		0				25		25	0		0	0		0
H5970	032	0	1	04	01	H5970_032_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H5970	032	0	1	04	01	H5970_032_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	25		25				25		25	25		25	25		25
H5970	032	0	1	04	01	H5970_032_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
H5970	032	0	1	04	01	H5970_032_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	25						25			25			25		25
H5989	011	0	1	01	01	H5989_011_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	1.00	2.00	2.50																			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, Select Care Drugs	1.00	2.00	2.50				1.00	2.00	2.50				1.00		1.00	25	25	25				25	25	25				25		25
H5989	011	0	1	01	01	H5989_011_0	6			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	5.00																			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, Select Care Drugs	2.00	4.00	5.00				2.00	4.00	5.00				2.00		2.00	25	25	25				25	25	25				25		25
H5989	011	0	1	01	01	H5989_011_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				45.54	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		35.00	19	19	19				19	19	19				19		19
H5989	011	0	1	01	01	H5989_011_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				26.30	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	25	25	25				25	25	25				25		25
H5989	011	0	1	01	01	H5989_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H5989	011	0	1	01	01	H5989_011_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	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H5992	007	0	1	01	01	H5992_007_0	9		N	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																														
H5992	007	0	1	01	01	H5992_007_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.06	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5992	007	0	1	01	01	H5992_007_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				34.14	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	20	20	20				20	20	20				20		20
H5992	007	0	1	01	01	H5992_007_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.71	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		35.00	25	25	25				25	25	25				25		25
H5992	007	0	1	01	01	H5992_007_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				430.56	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	25						25						25		25
H5992	007	0	1	01	01	H5992_007_0	9		N	Select Care Drugs	4	01	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																														
H5992	010	0	1	01	01	H5992_010_0	8		N	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																														
H5992	010	0	1	01	01	H5992_010_0	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H5992	010	0	1	01	01	H5992_010_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				34.30	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	20	20	20				20	20	20				20		20
H5992	010	0	1	01	01	H5992_010_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.14	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		35.00	25	25	25				25	25	25				25		25
H5992	010	0	1	01	01	H5992_010_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				541.51	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	25						25						25		25
H5992	010	0	1	01	01	H5992_010_0	8		N	Select Care Drugs	4	01	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																														
H5995	004	0	1	01	01	H5995_004_0	7			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	7			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	25		25						25				25		25
H5995	004	0	1	01	01	H5995_004_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						0				25		25
H5995	004	0	1	01	01	H5995_004_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						0				25		25
H5995	004	0	1	01	01	H5995_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				397.01	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	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6018	002	0	1	04	01	H6018_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	0	0	0				0	0	0				0		0
H6018	002	0	1	04	01	H6018_002_0	6			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	25	25	25				25	25	25				25		25
H6018	002	0	1	04	01	H6018_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				58.00	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		35.00	23	23	23				23	23	23				23		23
H6018	002	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	002	0	1	04	01	H6018_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	25						25						25		25
H6018	003	0	1	04	01	H6018_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	0	0	0				0	0	0				0		0
H6018	003	0	1	04	01	H6018_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	25	25	25				25	25	25				25		25
H6018	003	0	1	04	01	H6018_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				60.00	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	22	22	22				22	22	22				22		22
H6018	003	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	003	0	1	04	01	H6018_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	25						25						25		25
H6018	007	0	1	04	01	H6018_007_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	0	0	0				0	0	0				0		0
H6018	007	0	1	04	01	H6018_007_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6018	007	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	007	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	007	0	1	04	01	H6018_007_0	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	25						25						25		25
H6018	008	0	1	04	01	H6018_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	0	0	0				0	0	0				0		0
H6018	008	0	1	04	01	H6018_008_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	25	25	25				25	25	25				25		25
H6018	008	0	1	04	01	H6018_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				39.00	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	21	21	21				21	21	21				21		21
H6018	008	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	008	0	1	04	01	H6018_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	25						25						25		25
H6018	010	0	1	04	01	H6018_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6018	010	0	1	04	01	H6018_010_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	0	0	0				0	0	0				0		0
H6018	010	0	1	04	01	H6018_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				33.00	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	19	19	19				19	19	19				19		19
H6018	010	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	010	0	1	04	01	H6018_010_0	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	25						25						25		25
H6018	011	0	1	04	01	H6018_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6018	011	0	1	04	01	H6018_011_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	25	25	25				25	25	25				25		25
H6018	011	0	1	04	01	H6018_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				39.00	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	21	21	21				21	21	21				21		21
H6018	011	0	1	04	01	H6018_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				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	25	25	25				25	25	25				25		25
H6018	011	0	1	04	01	H6018_011_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	25						25						25		25
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				6.03	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	24	24	24				24	24	24				24		24
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				94.01	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	25	25	25				25	25	25				25		25
H6154	001	0	1	02	01	H6154_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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6154	001	0	1	02	01	H6154_001_0	4			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	7.00	14.00	21.00																									20.00	40.00	60.00				7.00	14.00	21.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6154	001	0	1	02	01	H6154_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				38.34	16	16	16																								16	16	16				16	16	16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	16	16	16				16	16	16	16	16	16	16		16
H6154	001	0	1	02	01	H6154_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				88.52	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H6154	001	0	1	02	01	H6154_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																														
H6158	001	0	1	01	01	H6158_001_0	5			Preferred Generic	4	11	1	2	1	1	110		01			1	30		100				1	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																														
H6158	001	0	1	01	01	H6158_001_0	5			Generic	4	11	1	2	2	1	110		01			1	30		100				1	2							30		31	5.00		12.50																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6158	001	0	1	01	01	H6158_001_0	5			Preferred Brand	4	11	1	1	3	1	110		01			1	30		100				1	2							30		31				29.42	17		17																																			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	17		17										17		17
H6158	001	0	1	01	01	H6158_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01			1	30		100				1	2							30		31				66.41	34		34																																			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H6158	001	0	1	01	01	H6158_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01			1	30														30		31				614.69	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H6158	003	0	1	01	01	H6158_003_0	5			Preferred Generic	3	11	1	2	1	1	110		01			1	30		100				1	2							30		31	4.00		12.00																																					4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6158	003	0	1	01	01	H6158_003_0	5			Generic	3	11	1	2	2	1	110		01			1	30		100				1	2							30		31	14.00		42.00																																					14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6158	003	0	1	01	01	H6158_003_0	5			Preferred Brand	3	11	1	1	3	1	110		01			1	30		100				1	2							30		31				34.38	20		20																																			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	20		20										20		20
H6158	003	0	1	01	01	H6158_003_0	5			Non-Preferred Drug	3	11	1	1	4	1	110		01			1	30		100				1	2							30		31				65.70	34		34																																			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H6158	003	0	1	01	01	H6158_003_0	5			Specialty Tier	3	11	1	1	5	1	010		01			1	30														30		31				471.62	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H6170	001	0	1	02	01	H6170_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	001	0	1	02	01	H6170_001_0	9			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	25		25						25				25		25
H6170	001	0	1	02	01	H6170_001_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6170	001	0	1	02	01	H6170_001_0	9			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						40.00				20.00		20.00	25		25						25				25		25
H6170	001	0	1	02	01	H6170_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1110.48	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	001	0	1	02	01	H6170_001_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	002	0	1	02	01	H6170_002_0	12			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	0		0						0				0		0
H6170	002	0	1	02	01	H6170_002_0	12			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	0		0						0				0		0
H6170	002	0	1	02	01	H6170_002_0	12			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				92.02	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	002	0	1	02	01	H6170_002_0	12			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				88.31	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	002	0	1	02	01	H6170_002_0	12			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				661.82	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	002	0	1	02	01	H6170_002_0	12			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	0		0						0				0		0
H6170	003	0	1	02	01	H6170_003_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	003	0	1	02	01	H6170_003_0	10			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	0		0						0				0		0
H6170	003	0	1	02	01	H6170_003_0	10			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				92.02	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	003	0	1	02	01	H6170_003_0	10			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				88.31	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	003	0	1	02	01	H6170_003_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				661.82	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	003	0	1	02	01	H6170_003_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	007	0	1	01	01	H6170_007_0	8			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	0		0						0				0		0
H6170	007	0	1	01	01	H6170_007_0	8			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	25		25						25				25		25
H6170	007	0	1	01	01	H6170_007_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6170	007	0	1	01	01	H6170_007_0	8			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						40.00				20.00		20.00	25		25						25				25		25
H6170	007	0	1	01	01	H6170_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1191.87	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	007	0	1	01	01	H6170_007_0	8			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	0		0						0				0		0
H6170	008	0	1	01	01	H6170_008_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	008	0	1	01	01	H6170_008_0	7			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	25		25						25				25		25
H6170	008	0	1	01	01	H6170_008_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6170	008	0	1	01	01	H6170_008_0	7			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	008	0	1	01	01	H6170_008_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				979.21	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	008	0	1	01	01	H6170_008_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	009	0	1	01	01	H6170_009_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	009	0	1	01	01	H6170_009_0	11			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	0		0						0				0		0
H6170	009	0	1	01	01	H6170_009_0	11			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				105.15	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	009	0	1	01	01	H6170_009_0	11			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				41.76	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	009	0	1	01	01	H6170_009_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				703.60	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	009	0	1	01	01	H6170_009_0	11			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	0		0						0				0		0
H6170	010	0	1	01	01	H6170_010_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6170	010	0	1	01	01	H6170_010_0	10			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	0		0						0				0		0
H6170	010	0	1	01	01	H6170_010_0	10			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				93.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	010	0	1	01	01	H6170_010_0	10			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				67.94	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6170	010	0	1	01	01	H6170_010_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				565.36	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6170	010	0	1	01	01	H6170_010_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6200	001	0	1	04	01	H6200_001_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H6200	001	0	1	04	01	H6200_001_0	9			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					5.00	10.00	15.00					5.00	10.00	10.00																12.00				12.00			0.40	0.17	0.17			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	5.00	10.00	10.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H6200	001	0	1	04	01	H6200_001_0	9			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	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	001	0	1	04	01	H6200_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											62.37	50	50	50				62.37	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	001	0	1	04	01	H6200_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											742.67	29						742.67	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	004	0	1	04	01	H6200_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								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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H6200	004	0	1	04	01	H6200_004_0	8			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H6200	004	0	1	04	01	H6200_004_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	004	0	1	04	01	H6200_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											53.15	50	50	50				53.15	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	004	0	1	04	01	H6200_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											609.76	29						609.76	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	006	0	1	04	01	H6200_006_0	8			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H6200	006	0	1	04	01	H6200_006_0	8			Generic	4	01	3	2	2	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					3.00	6.00	6.00																12.00				12.00			0.40	0.10	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	3.00	6.00	6.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H6200	006	0	1	04	01	H6200_006_0	8			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	006	0	1	04	01	H6200_006_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											58.06	50	50	50				58.06	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	006	0	1	04	01	H6200_006_0	8			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											746.47	29						746.47	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	008	0	1	04	01	H6200_008_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								15.00	30.00	45.00					0.00	0.00	0.00					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	15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00	25	25	25	0	0	0	0	0	0				25		25
H6200	008	0	1	04	01	H6200_008_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					3.00	6.00	9.00					3.00	6.00	6.00																20.00				20.00			0.67	0.10	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	3.00	6.00	6.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
H6200	008	0	1	04	01	H6200_008_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	008	0	1	04	01	H6200_008_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											63.32	50	50	50				63.32	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	008	0	1	04	01	H6200_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											689.76	25						689.76	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	009	0	1	04	01	H6200_009_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H6200	009	0	1	04	01	H6200_009_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					5.00	10.00	15.00					5.00	10.00	10.00																12.00				12.00			0.40	0.17	0.17			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	5.00	10.00	10.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H6200	009	0	1	04	01	H6200_009_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	009	0	1	04	01	H6200_009_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											63.23	50	50	50				63.23	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	009	0	1	04	01	H6200_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											779.18	29						779.18	29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	010	0	1	04	01	H6200_010_0	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					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	4.00	8.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00				4.00		4.00	25	25	25	0	0	0	0	0	0				25		25
H6200	010	0	1	04	01	H6200_010_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								12.00	24.00	36.00					5.00	10.00	15.00					5.00	10.00	10.00																12.00				12.00			0.40	0.17	0.17			0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	5.00	10.00	10.00				12.00		12.00	25	25	25	25	25	25	25	25	25				25		25
H6200	010	0	1	04	01	H6200_010_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	010	0	1	04	01	H6200_010_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											45.16	50	50	50				45.16	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	010	0	1	04	01	H6200_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											751.08	33						751.08	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6200	011	0	1	04	01	H6200_011_0	7			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								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	15.00	30.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00				15.00		15.00	25	25	25	0	0	0	0	0	0				25		25
H6200	011	0	1	04	01	H6200_011_0	7			Generic	4	01	3	2	2	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								20.00	40.00	60.00					3.00	6.00	9.00					3.00	6.00	6.00																20.00				20.00			0.67	0.10	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	3.00	6.00	6.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
H6200	011	0	1	04	01	H6200_011_0	7			Preferred Brand	4	10	1	2	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								47.00	94.00	141.00					47.00	94.00	141.00					47.00	94.00	94.00																47.00				47.00			1.57	1.57	1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	94.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	011	0	1	04	01	H6200_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											63.32	50	50	50				63.32	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6200	011	0	1	04	01	H6200_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											689.76	25						689.76	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6202	004	0	1	04	01	H6202_004_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6202	004	0	1	04	01	H6202_004_0	7			Generic	4	01	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	7.50																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6202	004	0	1	04	01	H6202_004_0	7			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				41.37	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	20	20	20				20	20	20				20		20
H6202	004	0	1	04	01	H6202_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				44.88	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6202	004	0	1	04	01	H6202_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1069.45	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6202	005	0	1	04	01	H6202_005_0	7			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6202	005	0	1	04	01	H6202_005_0	7			Generic	4	01	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	7.50																3.00				3.00		0.10			0.10			0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6202	005	0	1	04	01	H6202_005_0	7			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.57	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	20	20	20				20	20	20				20		20
H6202	005	0	1	04	01	H6202_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				44.46	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	20	20	20				20	20	20				20		20
H6202	005	0	1	04	01	H6202_005_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1059.38	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	20						20						20		20
H6237	009	0	1	01	01	H6237_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								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6237	009	0	1	01	01	H6237_009_0	6			Generic	4	01	1	2	2	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6237	009	0	1	01	01	H6237_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								23.00	46.00	69.00					18.00	36.00	54.00											23.00	46.00	69.00				18.00	36.00	54.00				23.00				23.00			0.77	0.60		0.77	0.60	0.74	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	23.00	46.00	69.00	18.00	36.00	54.00	23.00	46.00	69.00	18.00	36.00	54.00	23.00		23.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6237	009	0	1	01	01	H6237_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											52.30	33	33	33				52.30	30	30	30										33	33	33				30	30	30			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6237	009	0	1	01	01	H6237_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											848.49	30						848.49	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6248	001	0	1	01	01	H6248_001_0	4			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	0	0	0						0				0		0
H6248	001	0	1	01	01	H6248_001_0	4			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	25	25	25						25				25		25
H6248	001	0	1	01	01	H6248_001_0	4			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	25	25	25						25				25		25
H6248	001	0	1	01	01	H6248_001_0	4			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	31	62	93				2	2			93				31		31				71.01	50	50	50																				50															50			50								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	25	25	25						25				25		25
H6248	001	0	1	01	01	H6248_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				813.00	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	25						25						25		25
H6248	001	0	1	01	01	H6248_001_0	4			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	31	62	100				2	2			100				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	0	0	0						0				0		0
H6309	001	0	1	04	01	H6309_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																														
H6309	001	0	1	04	01	H6309_001_0	8			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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H6309	001	0	1	04	01	H6309_001_0	8			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				1	2	30		90				30		31				83.37	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	20		20				20		20				20		20
H6309	001	0	1	04	01	H6309_001_0	8			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				1	2	30		90				30		31				80.59	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		35.00	25		25				25		25				25		25
H6309	001	0	1	04	01	H6309_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				446.96	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6309	002	0	1	04	01	H6309_002_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6309	002	0	1	04	01	H6309_002_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H6309	002	0	1	04	01	H6309_002_0	6			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				1	2	30		90				30		31				83.78	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	20		20				20		20				20		20
H6309	002	0	1	04	01	H6309_002_0	6			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				1	2	30		90				30		31				82.59	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		35.00	25		25				25		25				25		25
H6309	002	0	1	04	01	H6309_002_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				458.27	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6316	002	0	1	01	01	H6316_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		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																														
H6316	002	0	1	01	01	H6316_002_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6316	002	0	1	01	01	H6316_002_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				68.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6316	002	0	1	01	01	H6316_002_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		34				29.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6316	002	0	1	01	01	H6316_002_0	5		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																														
H6316	002	0	1	01	01	H6316_002_0	5		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																														
H6316	005	0	1	01	01	H6316_005_0	5		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																														
H6316	005	0	1	01	01	H6316_005_0	5		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, Select Care Drugs																														
H6316	005	0	1	01	01	H6316_005_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				74.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6316	005	0	1	01	01	H6316_005_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		34				32.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6316	005	0	1	01	01	H6316_005_0	5		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																														
H6316	005	0	1	01	01	H6316_005_0	5		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																														
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	0	0	0						0				0		0
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	25	25	25						25				25		25
H6322	001	0	1	01	01	H6322_001_0	7			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				2000.00	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						79.00				35.00		35.00	25	25	25						25				25		25
H6322	001	0	1	01	01	H6322_001_0	7			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				33.67	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						79.00				35.00		35.00	25	25	25						25				25		25
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				99999.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0						0				0		0
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	0	0	0						0				0		0
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	25	25	25						25				25		25
H6322	002	0	1	01	01	H6322_002_0	7			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				2000.00	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						79.00				35.00		35.00	25	25	25						25				25		25
H6322	002	0	1	01	01	H6322_002_0	7			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				42.14	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						79.00				35.00		35.00	25	25	25						25				25		25
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				2000.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0						0				0		0
H6322	008	0	1	01	01	H6322_008_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	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6322	008	0	1	01	01	H6322_008_0	8			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	25	25	25						25				25		25
H6322	008	0	1	01	01	H6322_008_0	8			Preferred Brand	4	10	1	1	3	1	111		01	100		1	30	60	90				2	2			90				30		31				2000.00	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						79.00				35.00		35.00	25	25	25						25				25		25
H6322	008	0	1	01	01	H6322_008_0	8			Non-Preferred Brand	4	10	1	1	4	1	111		01	100		1	30	60	90				2	2			90				30		31				35.42	30	30	30																				30															30			30								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	25	25	25						25				25		25
H6322	008	0	1	01	01	H6322_008_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				2000.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6322	008	0	1	01	01	H6322_008_0	8			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	0	0	0						0				0		0
H6341	001	0	1	01	01	H6341_001_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				5.83	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6341	001	0	1	01	01	H6341_001_0	6		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				17.68	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6341	001	0	1	01	01	H6341_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				98.74	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6341	001	0	1	01	01	H6341_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				19.00	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6341	001	0	1	01	01	H6341_001_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				515.12	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6341	001	0	1	01	01	H6341_001_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6348	002	0	1	04	01	H6348_002_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6348	002	0	1	04	01	H6348_002_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6348	002	0	1	04	01	H6348_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											124.55	25	25	25				124.55	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6348	002	0	1	04	01	H6348_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											71.60	36	36	36				69.61	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6348	002	0	1	04	01	H6348_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6348	002	0	1	04	01	H6348_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6348	008	0	1	04	01	H6348_008_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6348	008	0	1	04	01	H6348_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											120.24	25	25	25				120.24	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6348	008	0	1	04	01	H6348_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											61.31	35	35	35				59.56	34	34	34											35	35					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6348	008	0	1	04	01	H6348_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6348	008	0	1	04	01	H6348_008_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6348	009	0	1	04	01	H6348_009_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.79	20	20	20				77.79	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H6348	009	0	1	04	01	H6348_009_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6348	009	0	1	04	01	H6348_009_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	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, Select Diabetic Drugs																														
H6351	004	0	1	01	01	H6351_004_0	8			Generic	4	01	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, Select Diabetic Drugs																														
H6351	004	0	1	01	01	H6351_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	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 Drug, Specialty Tier, Select Diabetic Drugs																														
H6351	004	0	1	01	01	H6351_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	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 Drug, Specialty Tier, Select Diabetic Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6351	004	0	1	01	01	H6351_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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Diabetic Drugs																														
H6351	004	0	1	01	01	H6351_004_0	8			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 Drug, Specialty Tier, Select Diabetic Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6368	001	0	1	01	01	H6368_001_0	7			Preferred Generic	4	01	1	2	1	1	111		10	100		1	30	60	90				2	2			90					14	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6368	001	0	1	01	01	H6368_001_0	7			Generic	4	01	3	2	2	1	111		10	100		1	30	60	90				2	2			90					14	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6368	001	0	1	01	01	H6368_001_0	7			Preferred Brand	4	11	1	2	3	1	111		10	100		1	30	60	90				2	2			90					14	31	35.00	70.00	105.00																					105.00																	35.00			35.00		1.17						1.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H6368	001	0	1	01	01	H6368_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	010		10	000		1	30															14	31	98.00																																								98.00			98.00		3.27						3.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6368	001	0	1	01	01	H6368_001_0	7			Specialty Tier	4	11	1	1	5	1	010		10	000		1	30															14	31				728.57	33																																						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6368	001	0	1	01	01	H6368_001_0	7			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6368	002	0	1	01	01	H6368_002_0	7			Preferred Generic	4	01	1	2	1	1	111		10	100		1	30	60	90				2	2			90					14	31	0.00	0.00	0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6368	002	0	1	01	01	H6368_002_0	7			Generic	4	01	3	2	2	1	111		10	100		1	30	60	90				2	2			90					14	31	7.00	14.00	21.00																					21.00																	7.00			7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	7.00	14.00	21.00						21.00				7.00		7.00	25	25	25						25				25		25
H6368	002	0	1	01	01	H6368_002_0	7			Preferred Brand	4	11	1	2	3	1	111		10	100		1	30	60	90				2	2			90					14	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	25	25	25						25				25		25
H6368	002	0	1	01	01	H6368_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		10	000		1	30															14	31				48.81	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6368	002	0	1	01	01	H6368_002_0	7			Specialty Tier	4	11	1	1	5	1	010		10	000		1	30															14	31				731.83	33																																						33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6368	002	0	1	01	01	H6368_002_0	7			Select Care Drugs	4	11	1	2	6	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H6378	001	0	1	01	01	H6378_001_0	6		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				3.96	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6378	001	0	1	01	01	H6378_001_0	6		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				10.99	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6378	001	0	1	01	01	H6378_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				94.27	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6378	001	0	1	01	01	H6378_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				21.93	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H6378	001	0	1	01	01	H6378_001_0	6		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				543.17	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6378	001	0	1	01	01	H6378_001_0	6		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	001	0	1	01	01	H6379_001_0	8			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	001	0	1	01	01	H6379_001_0	8			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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	001	0	1	01	01	H6379_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											58.66	20	20	20				58.66	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H6379	001	0	1	01	01	H6379_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											92.91	34	34	34				92.91	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6379	001	0	1	01	01	H6379_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											898.23	28						898.23	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H6379	001	0	1	01	01	H6379_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	002	0	1	01	01	H6379_002_0	7			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	002	0	1	01	01	H6379_002_0	7			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6379	002	0	1	01	01	H6379_002_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.13	20	20	20				51.13	20	20	20										20	20	20				20	20	20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H6379	002	0	1	01	01	H6379_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											85.27	35	35	35				85.27	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6379	002	0	1	01	01	H6379_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											934.80	30						934.80	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H6379	002	0	1	01	01	H6379_002_0	7			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6396	017	0	1	01	01	H6396_017_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6396	017	0	1	01	01	H6396_017_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31				6.05	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6396	017	0	1	01	01	H6396_017_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31				54.16	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6396	017	0	1	01	01	H6396_017_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31				49.24	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6396	017	0	1	01	01	H6396_017_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				473.88	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	013	1	1	02	01	H6453_013_1	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	1	1	02	01	H6453_013_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											69.87	50	50	50				54.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	1	1	02	01	H6453_013_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1089.32	29						810.72	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	013	2	1	02	01	H6453_013_2	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	2	1	02	01	H6453_013_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											69.87	50	50	50				54.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	2	1	02	01	H6453_013_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1089.32	29						810.72	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	013	3	1	02	01	H6453_013_3	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	3	1	02	01	H6453_013_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											69.87	50	50	50				54.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	3	1	02	01	H6453_013_3	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1089.32	29						810.72	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	013	4	1	02	01	H6453_013_4	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	4	1	02	01	H6453_013_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											69.87	50	50	50				54.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	4	1	02	01	H6453_013_4	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1089.32	29						810.72	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	013	5	1	02	01	H6453_013_5	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	5	1	02	01	H6453_013_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											69.87	50	50	50				54.58	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	013	5	1	02	01	H6453_013_5	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1089.32	29						810.72	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	017	1	1	02	01	H6453_017_1	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	017	1	1	02	01	H6453_017_1	12			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	50	50	50				65.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	017	1	1	02	01	H6453_017_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1233.78	29						677.21	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	017	2	1	02	01	H6453_017_2	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	017	2	1	02	01	H6453_017_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											62.31	50	50	50				65.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	017	2	1	02	01	H6453_017_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1233.78	29						677.21	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	018	1	1	02	01	H6453_018_1	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	018	1	1	02	01	H6453_018_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											58.32	50	50	50				46.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	018	1	1	02	01	H6453_018_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											876.62	29						686.88	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	018	2	1	02	01	H6453_018_2	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	018	2	1	02	01	H6453_018_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											58.32	50	50	50				46.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	018	2	1	02	01	H6453_018_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											876.62	29						686.88	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	019	0	1	02	01	H6453_019_0	13		N	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																														
H6453	019	0	1	02	01	H6453_019_0	13		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				6.21	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	019	0	1	02	01	H6453_019_0	13		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.08	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	25	25	25				25	25	25				25		25
H6453	019	0	1	02	01	H6453_019_0	13		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.19	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	25	25	25				25	25	25				25		25
H6453	019	0	1	02	01	H6453_019_0	13		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				939.91	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	020	1	1	02	01	H6453_020_1	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	020	1	1	02	01	H6453_020_1	12			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											82.37	50	50	50				72.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	020	1	1	02	01	H6453_020_1	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1360.46	29						868.94	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6453	020	2	1	02	01	H6453_020_2	12			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	12			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	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	020	2	1	02	01	H6453_020_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											82.37	50	50	50				72.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6453	020	2	1	02	01	H6453_020_2	12			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1360.46	29						868.94	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6474	001	0	1	02	01	H6474_001_0	8			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	0		0						0				0		0
H6474	001	0	1	02	01	H6474_001_0	8			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	25		25						25				25		25
H6474	001	0	1	02	01	H6474_001_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6474	001	0	1	02	01	H6474_001_0	8			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						40.00				20.00		20.00	25		25						25				25		25
H6474	001	0	1	02	01	H6474_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1090.95	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	001	0	1	02	01	H6474_001_0	8			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	0		0						0				0		0
H6474	002	0	1	02	01	H6474_002_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	002	0	1	02	01	H6474_002_0	9			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	0		0						0				0		0
H6474	002	0	1	02	01	H6474_002_0	9			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				92.02	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	002	0	1	02	01	H6474_002_0	9			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				88.31	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	002	0	1	02	01	H6474_002_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				661.82	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	002	0	1	02	01	H6474_002_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	003	0	1	02	01	H6474_003_0	8			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	0		0						0				0		0
H6474	003	0	1	02	01	H6474_003_0	8			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	0		0						0				0		0
H6474	003	0	1	02	01	H6474_003_0	8			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				92.02	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	003	0	1	02	01	H6474_003_0	8			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				88.31	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	003	0	1	02	01	H6474_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				661.82	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	003	0	1	02	01	H6474_003_0	8			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	0		0						0				0		0
H6474	007	0	1	01	01	H6474_007_0	8			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	0		0						0				0		0
H6474	007	0	1	01	01	H6474_007_0	8			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	25		25						25				25		25
H6474	007	0	1	01	01	H6474_007_0	8			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6474	007	0	1	01	01	H6474_007_0	8			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						40.00				20.00		20.00	25		25						25				25		25
H6474	007	0	1	01	01	H6474_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				1191.87	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	007	0	1	01	01	H6474_007_0	8			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	0		0						0				0		0
H6474	008	0	1	01	01	H6474_008_0	7			Preferred Generic	4	01	3	2	1	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	008	0	1	01	01	H6474_008_0	7			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	25		25						25				25		25
H6474	008	0	1	01	01	H6474_008_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	30		100				1	2			100				30		31	47.00		105.00																					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						40.00				20.00		20.00	25		25						25				25		25
H6474	008	0	1	01	01	H6474_008_0	7			Non-Preferred Brand	4	11	1	2	4	1	110		01	100		1	30		100				1	2			100				30		31	100.00		300.00																					200.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	008	0	1	01	01	H6474_008_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				979.21	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	008	0	1	01	01	H6474_008_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	30		100				1	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	009	0	1	01	01	H6474_009_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	009	0	1	01	01	H6474_009_0	11			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	0		0						0				0		0
H6474	009	0	1	01	01	H6474_009_0	11			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				105.15	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	009	0	1	01	01	H6474_009_0	11			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				41.76	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	009	0	1	01	01	H6474_009_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				703.60	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	009	0	1	01	01	H6474_009_0	11			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	0		0						0				0		0
H6474	010	0	1	01	01	H6474_010_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 Brand, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H6474	010	0	1	01	01	H6474_010_0	11			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	0		0						0				0		0
H6474	010	0	1	01	01	H6474_010_0	11			Preferred Brand	4	10	1	1	3	1	110		01	100		1	30		100				1	2			100				30		31				93.09	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	010	0	1	01	01	H6474_010_0	11			Non-Preferred Brand	4	11	1	1	4	1	110		01	100		1	30		100				1	2			100				30		31				67.94	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	20.00		60.00						40.00				20.00		20.00	25		25						25				25		25
H6474	010	0	1	01	01	H6474_010_0	11			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				565.36	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H6474	010	0	1	01	01	H6474_010_0	11			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	0		0						0				0		0
H6515	001	0	1	01	01	H6515_001_0	9		N	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																														
H6515	001	0	1	01	01	H6515_001_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.91	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6515	001	0	1	01	01	H6515_001_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				32.19	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	20	20	20				20	20	20				20		20
H6515	001	0	1	01	01	H6515_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.14	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		35.00	25	25	25				25	25	25				25		25
H6515	001	0	1	01	01	H6515_001_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				527.55	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	25						25						25		25
H6515	001	0	1	01	01	H6515_001_0	9		N	Select Care Drugs	4	01	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																														
H6515	002	0	1	01	01	H6515_002_0	9		N	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																														
H6515	002	0	1	01	01	H6515_002_0	9		N	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																														
H6515	002	0	1	01	01	H6515_002_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				27.46	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	20	20	20				20	20	20				20		20
H6515	002	0	1	01	01	H6515_002_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				58.41	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		35.00	25	25	25				25	25	25				25		25
H6515	002	0	1	01	01	H6515_002_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				484.84	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	25						25						25		25
H6515	002	0	1	01	01	H6515_002_0	9		N	Select Care Drugs	4	01	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																														
H6515	003	0	1	01	01	H6515_003_0	9		N	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																														
H6515	003	0	1	01	01	H6515_003_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.69	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6515	003	0	1	01	01	H6515_003_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				30.84	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	20	20	20				20	20	20				20		20
H6515	003	0	1	01	01	H6515_003_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.46	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		35.00	25	25	25				25	25	25				25		25
H6515	003	0	1	01	01	H6515_003_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				497.66	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	25						25						25		25
H6515	003	0	1	01	01	H6515_003_0	9		N	Select Care Drugs	4	01	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																														
H6515	004	0	1	01	01	H6515_004_0	9		N	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																														
H6515	004	0	1	01	01	H6515_004_0	9		N	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																														
H6515	004	0	1	01	01	H6515_004_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				26.08	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		35.00	20	20	20				20	20	20				20		20
H6515	004	0	1	01	01	H6515_004_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				57.75	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		35.00	25	25	25				25	25	25				25		25
H6515	004	0	1	01	01	H6515_004_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				548.62	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	25						25						25		25
H6515	004	0	1	01	01	H6515_004_0	9		N	Select Care Drugs	4	01	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																														
H6515	005	0	1	01	01	H6515_005_0	9		N	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																														
H6515	005	0	1	01	01	H6515_005_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				6.01	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6515	005	0	1	01	01	H6515_005_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				43.41	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	20	20	20				20	20	20				20		20
H6515	005	0	1	01	01	H6515_005_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				61.76	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		35.00	25	25	25				25	25	25				25		25
H6515	005	0	1	01	01	H6515_005_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				470.25	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	25						25						25		25
H6515	005	0	1	01	01	H6515_005_0	9		N	Select Care Drugs	4	01	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																														
H6529	004	0	1	01	01	H6529_004_0	7			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					2.00	4.00	0.00																	0.00			0.00			0.00	0.00	0.07			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	2.00	4.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H6529	004	0	1	01	01	H6529_004_0	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					8.00	16.00	0.00																	0.00			0.00			0.00	0.00	0.27			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	8.00	16.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H6529	004	0	1	01	01	H6529_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25				25		25
H6529	004	0	1	01	01	H6529_004_0	7			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											72.98	33	33	33				78.73	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	25	25	25	25	25	25	25	25	25				25		25
H6529	004	0	1	01	01	H6529_004_0	7			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	25			25									25		25
H6529	004	0	1	01	01	H6529_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	100	1	2	30	60	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	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	0	0	0	0	0	0	0	0	0				0		0
H6545	001	0	1	04	01	H6545_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	0	0	0				0	0	0				0		0
H6545	001	0	1	04	01	H6545_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6545	001	0	1	04	01	H6545_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				38.00	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		35.00	23	23	23				23	23	23				23		23
H6545	001	0	1	04	01	H6545_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6545	001	0	1	04	01	H6545_001_0	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	25						25						25		25
H6545	010	0	1	04	01	H6545_010_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	0	0	0				0	0	0				0		0
H6545	010	0	1	04	01	H6545_010_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6545	010	0	1	04	01	H6545_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				32.00	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	19	19	19				19	19	19				19		19
H6545	010	0	1	04	01	H6545_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				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	25	25	25				25	25	25				25		25
H6545	010	0	1	04	01	H6545_010_0	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	25						25						25		25
H6550	003	0	1	02	01	H6550_003_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6550	003	0	1	02	01	H6550_003_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6550	003	0	1	02	01	H6550_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											132.83	25	25	25				132.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6550	003	0	1	02	01	H6550_003_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.52	36	36	36				70.52	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6550	003	0	1	02	01	H6550_003_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	003	0	1	02	01	H6550_003_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	004	0	1	02	01	H6550_004_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	004	0	1	02	01	H6550_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	004	0	1	02	01	H6550_004_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.41	22	22	22				91.41	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		70.00	105.00		70.00	105.00	35.00		35.00	22	22	22	22	22	22		22	22		22	22	22		22
H6550	004	0	1	02	01	H6550_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6550	004	0	1	02	01	H6550_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	004	0	1	02	01	H6550_004_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	009	0	1	02	01	H6550_009_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	009	0	1	02	01	H6550_009_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	009	0	1	02	01	H6550_009_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											81.05	20	20	20				81.05	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H6550	009	0	1	02	01	H6550_009_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6550	009	0	1	02	01	H6550_009_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6550	009	0	1	02	01	H6550_009_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	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	0	0	0				0	0	0				0		0
H6586	001	0	1	04	01	H6586_001_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	0	0	0				0	0	0				0		0
H6586	001	0	1	04	01	H6586_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				37.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H6586	001	0	1	04	01	H6586_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				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	25	25	25				25	25	25				25		25
H6586	001	0	1	04	01	H6586_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	25						25						25		25
H6586	002	0	1	04	01	H6586_002_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	0	0	0				0	0	0				0		0
H6586	002	0	1	04	01	H6586_002_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																			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	25	25	25				25	25	25				25		25
H6586	002	0	1	04	01	H6586_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				59.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H6586	002	0	1	04	01	H6586_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				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	25	25	25				25	25	25				25		25
H6586	002	0	1	04	01	H6586_002_0	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	25						25						25		25
H6586	003	0	1	04	01	H6586_003_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H6586	003	0	1	04	01	H6586_003_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6586	003	0	1	04	01	H6586_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				63.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H6586	003	0	1	04	01	H6586_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				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	25	25	25				25	25	25				25		25
H6586	003	0	1	04	01	H6586_003_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	25						25						25		25
H6586	006	0	1	04	01	H6586_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	0	0	0				0	0	0				0		0
H6586	006	0	1	04	01	H6586_006_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	25	25	25				25	25	25				25		25
H6586	006	0	1	04	01	H6586_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				60.00	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	22	22	22				22	22	22				22		22
H6586	006	0	1	04	01	H6586_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				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	25	25	25				25	25	25				25		25
H6586	006	0	1	04	01	H6586_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	25						25						25		25
H6595	003	0	1	02	01	H6595_003_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H6595	003	0	1	02	01	H6595_003_0	4		N	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																														
H6595	003	0	1	02	01	H6595_003_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H6595	003	0	1	02	01	H6595_003_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				40.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6595	003	0	1	02	01	H6595_003_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				353.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6595	004	0	1	02	01	H6595_004_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H6595	004	0	1	02	01	H6595_004_0	4		N	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																														
H6595	004	0	1	02	01	H6595_004_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				55.00	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	25		25						25				25		25
H6595	004	0	1	02	01	H6595_004_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				35.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6595	004	0	1	02	01	H6595_004_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				341.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6595	005	0	1	02	01	H6595_005_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H6595	005	0	1	02	01	H6595_005_0	4		N	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																														
H6595	005	0	1	02	01	H6595_005_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				54.00	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	25		25						25				25		25
H6595	005	0	1	02	01	H6595_005_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				35.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6595	005	0	1	02	01	H6595_005_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				338.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6622	001	0	1	01	01	H6622_001_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	0		0				25		25	0		0	0		0
H6622	001	0	1	01	01	H6622_001_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	001	0	1	01	01	H6622_001_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	25		25				25		25	25		25	25		25
H6622	001	0	1	01	01	H6622_001_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	25		25				25		25	25		25	25		25
H6622	001	0	1	01	01	H6622_001_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	25						25			25			25		25
H6622	004	0	1	01	01	H6622_004_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	0		0				25		25	0		0	0		0
H6622	004	0	1	01	01	H6622_004_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	004	0	1	01	01	H6622_004_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	25		25				25		25	25		25	25		25
H6622	004	0	1	01	01	H6622_004_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	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	25		25				25		25	25		25	25		25
H6622	004	0	1	01	01	H6622_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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H6622	008	0	1	01	01	H6622_008_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	0		0				25		25	0		0	0		0
H6622	008	0	1	01	01	H6622_008_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	0		0				25		25	0		0	0		0
H6622	008	0	1	01	01	H6622_008_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	008	0	1	01	01	H6622_008_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	008	0	1	01	01	H6622_008_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	25						25			25			25		25
H6622	013	0	1	02	01	H6622_013_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	0		0				25		25	0		0	0		0
H6622	013	0	1	02	01	H6622_013_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	013	0	1	02	01	H6622_013_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	25		25				25		25	25		25	25		25
H6622	013	0	1	02	01	H6622_013_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	25		25				25		25	25		25	25		25
H6622	013	0	1	02	01	H6622_013_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	25						25			25			25		25
H6622	014	0	1	02	01	H6622_014_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	0		0				25		25	0		0	0		0
H6622	014	0	1	02	01	H6622_014_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	0		0				25		25	0		0	0		0
H6622	014	0	1	02	01	H6622_014_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	25		25				25		25	25		25	25		25
H6622	014	0	1	02	01	H6622_014_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	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	25		25				25		25	25		25	25		25
H6622	014	0	1	02	01	H6622_014_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	25						25			25			25		25
H6622	015	0	1	01	01	H6622_015_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	0		0				25		25	0		0	0		0
H6622	015	0	1	01	01	H6622_015_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	0		0				25		25	0		0	0		0
H6622	015	0	1	01	01	H6622_015_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	015	0	1	01	01	H6622_015_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	015	0	1	01	01	H6622_015_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	25						25			25			25		25
H6622	017	0	1	01	01	H6622_017_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	0		0				25		25	0		0	0		0
H6622	017	0	1	01	01	H6622_017_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	25		25				25		25	25		0	25		25
H6622	017	0	1	01	01	H6622_017_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	017	0	1	01	01	H6622_017_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	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	25		25				25		25	25		25	25		25
H6622	017	0	1	01	01	H6622_017_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H6622	017	0	1	01	01	H6622_017_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	0		0				25		25	0		0	0		0
H6622	018	0	1	01	01	H6622_018_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	0		0				25		25	0		0	0		0
H6622	018	0	1	01	01	H6622_018_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	0		0				25		25	0		0	0		0
H6622	018	0	1	01	01	H6622_018_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	018	0	1	01	01	H6622_018_0	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H6622	018	0	1	01	01	H6622_018_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	25						25			25			25		25
H6622	021	1	1	02	01	H6622_021_1	2			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	0		0				25		25	0		0	0		0
H6622	021	1	1	02	01	H6622_021_1	2			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	0		0				25		25	0		0	0		0
H6622	021	1	1	02	01	H6622_021_1	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	021	1	1	02	01	H6622_021_1	2			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	25		25				25		25	25		25	25		25
H6622	021	1	1	02	01	H6622_021_1	2			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	25						25			25			25		25
H6622	021	2	1	02	01	H6622_021_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	0		0				25		25	0		0	0		0
H6622	021	2	1	02	01	H6622_021_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	0		0				25		25	0		0	0		0
H6622	021	2	1	02	01	H6622_021_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	25		25				25		25	25		25	25		25
H6622	021	2	1	02	01	H6622_021_2	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	25		25				25		25	25		25	25		25
H6622	021	2	1	02	01	H6622_021_2	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	25						25			25			25		25
H6622	022	0	1	02	01	H6622_022_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	0		0				25		25	0		0	0		0
H6622	022	0	1	02	01	H6622_022_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	022	0	1	02	01	H6622_022_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	25		25				25		25	25		25	25		25
H6622	022	0	1	02	01	H6622_022_0	3			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	25		25				25		25	25		25	25		25
H6622	022	0	1	02	01	H6622_022_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	25						25			25			25		25
H6622	023	0	1	02	01	H6622_023_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	0		0				25		25	0		0	0		0
H6622	023	0	1	02	01	H6622_023_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	023	0	1	02	01	H6622_023_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	25		25				25		25	25		25	25		25
H6622	023	0	1	02	01	H6622_023_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	023	0	1	02	01	H6622_023_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	25						25			25			25		25
H6622	025	0	1	02	01	H6622_025_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	0		0				25		25	0		0	0		0
H6622	025	0	1	02	01	H6622_025_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	025	0	1	02	01	H6622_025_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	25		25				25		25	25		25	25		25
H6622	025	0	1	02	01	H6622_025_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H6622	025	0	1	02	01	H6622_025_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	25						25			25			25		25
H6622	026	0	1	02	01	H6622_026_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	0		0				25		25	0		0	0		0
H6622	026	0	1	02	01	H6622_026_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	026	0	1	02	01	H6622_026_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	25		25				25		25	25		25	25		25
H6622	026	0	1	02	01	H6622_026_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	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	25		25				25		25	25		25	25		25
H6622	026	0	1	02	01	H6622_026_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	25						25			25			25		25
H6622	027	0	1	02	01	H6622_027_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	0		0				25		25	0		0	0		0
H6622	027	0	1	02	01	H6622_027_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	0		0				25		25	0		0	0		0
H6622	027	0	1	02	01	H6622_027_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	027	0	1	02	01	H6622_027_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	027	0	1	02	01	H6622_027_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	25						25			25			25		25
H6622	028	0	1	01	01	H6622_028_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	0		0				25		25	0		0	0		0
H6622	028	0	1	01	01	H6622_028_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	25		25				25		25	25		0	25		25
H6622	028	0	1	01	01	H6622_028_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	25		25				25		25	25		25	25		25
H6622	028	0	1	01	01	H6622_028_0	3			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	25		25				25		25	25		25	25		25
H6622	028	0	1	01	01	H6622_028_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	25						25			25			25		25
H6622	029	0	1	01	01	H6622_029_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	0		0				25		25	0		0	0		0
H6622	029	0	1	01	01	H6622_029_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H6622	029	0	1	01	01	H6622_029_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	029	0	1	01	01	H6622_029_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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	25		25				25		25	25		25	25		25
H6622	029	0	1	01	01	H6622_029_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H6622	029	0	1	01	01	H6622_029_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	0		0				0		0	0		0	0		0
H6622	032	0	1	01	01	H6622_032_0	2			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	0		0				25		25	0		0	0		0
H6622	032	0	1	01	01	H6622_032_0	2			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	25		25				25		25	25		0	25		25
H6622	032	0	1	01	01	H6622_032_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	032	0	1	01	01	H6622_032_0	2			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	25		25				25		25	25		25	25		25
H6622	032	0	1	01	01	H6622_032_0	2			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	25						25			25			25		25
H6622	033	0	1	01	01	H6622_033_0	2			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	0		0				25		25	0		0	0		0
H6622	033	0	1	01	01	H6622_033_0	2			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	25		25				25		25	25		0	25		25
H6622	033	0	1	01	01	H6622_033_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	033	0	1	01	01	H6622_033_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				82.00	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	25		25				25		25	25		25	25		25
H6622	033	0	1	01	01	H6622_033_0	2			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	25						25			25			25		25
H6622	035	0	1	01	01	H6622_035_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	0		0				25		25	0		0	0		0
H6622	035	0	1	01	01	H6622_035_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	035	0	1	01	01	H6622_035_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	25		25				25		25	25		25	25		25
H6622	035	0	1	01	01	H6622_035_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	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	25		25				25		25	25		25	25		25
H6622	035	0	1	01	01	H6622_035_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	25						25			25			25		25
H6622	036	0	1	01	01	H6622_036_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	0		0				25		25	0		0	0		0
H6622	036	0	1	01	01	H6622_036_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	036	0	1	01	01	H6622_036_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	25		25				25		25	25		25	25		25
H6622	036	0	1	01	01	H6622_036_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	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	25		25				25		25	25		25	25		25
H6622	036	0	1	01	01	H6622_036_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	25						25			25			25		25
H6622	037	0	1	01	01	H6622_037_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	0		0				25		25	0		0	0		0
H6622	037	0	1	01	01	H6622_037_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	037	0	1	01	01	H6622_037_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	25		25				25		25	25		25	25		25
H6622	037	0	1	01	01	H6622_037_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	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	25		25				25		25	25		25	25		25
H6622	037	0	1	01	01	H6622_037_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	25						25			25			25		25
H6622	047	0	1	01	01	H6622_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	0		0				25		25	0		0	0		0
H6622	047	0	1	01	01	H6622_047_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	047	0	1	01	01	H6622_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	25		25				25		25	25		25	25		25
H6622	047	0	1	01	01	H6622_047_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H6622	047	0	1	01	01	H6622_047_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	25						25			25			25		25
H6622	048	0	1	01	01	H6622_048_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	0		0				25		25	0		0	0		0
H6622	048	0	1	01	01	H6622_048_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	0		0				25		25	0		0	0		0
H6622	048	0	1	01	01	H6622_048_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	048	0	1	01	01	H6622_048_0	5		N	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	25		25				25		25	25		25	25		25
H6622	048	0	1	01	01	H6622_048_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	25						25			25			25		25
H6622	054	0	1	01	01	H6622_054_0	2			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	0		0				25		25	0		0	0		0
H6622	054	0	1	01	01	H6622_054_0	2			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	25		25				25		25	25		0	25		25
H6622	054	0	1	01	01	H6622_054_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	054	0	1	01	01	H6622_054_0	2			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	25		25				25		25	25		25	25		25
H6622	054	0	1	01	01	H6622_054_0	2			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	25						25			25			25		25
H6622	055	0	1	01	01	H6622_055_0	2			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	0		0				25		25	0		0	0		0
H6622	055	0	1	01	01	H6622_055_0	2			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	25		25				25		25	25		0	25		25
H6622	055	0	1	01	01	H6622_055_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	055	0	1	01	01	H6622_055_0	2			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	25		25				25		25	25		25	25		25
H6622	055	0	1	01	01	H6622_055_0	2			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	25						25			25			25		25
H6622	056	0	1	01	01	H6622_056_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	0		0				25		25	0		0	0		0
H6622	056	0	1	01	01	H6622_056_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	0		0				25		25	0		0	0		0
H6622	056	0	1	01	01	H6622_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		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	25		25				25		25	25		25	25		25
H6622	056	0	1	01	01	H6622_056_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	056	0	1	01	01	H6622_056_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	25						25			25			25		25
H6622	057	0	1	02	01	H6622_057_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	0		0				25		25	0		0	0		0
H6622	057	0	1	02	01	H6622_057_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	25		25				25		25	25		0	25		25
H6622	057	0	1	02	01	H6622_057_0	5			Preferred Brand	4	11	1	2	3	1	110		01		110	1	30		100				2	2				30		100	30		31	47.00		141.00																									47.00		141.00				47.00		131.00				47.00				47.00		1.57				1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	057	0	1	02	01	H6622_057_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H6622	057	0	1	02	01	H6622_057_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H6622	060	0	1	02	01	H6622_060_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	0		0				25		25	0		0	0		0
H6622	060	0	1	02	01	H6622_060_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	060	0	1	02	01	H6622_060_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	25		25				25		25	25		25	25		25
H6622	060	0	1	02	01	H6622_060_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	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	25		25				25		25	25		25	25		25
H6622	060	0	1	02	01	H6622_060_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	25						25			25			25		25
H6622	061	0	1	02	01	H6622_061_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	0		0				25		25	0		0	0		0
H6622	061	0	1	02	01	H6622_061_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	061	0	1	02	01	H6622_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	25		25				25		25	25		25	25		25
H6622	061	0	1	02	01	H6622_061_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H6622	061	0	1	02	01	H6622_061_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	25						25			25			25		25
H6622	071	0	1	01	01	H6622_071_0	2			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	0		0				25		25	0		0	0		0
H6622	071	0	1	01	01	H6622_071_0	2			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, Select Care Drugs	9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00	25		25				25		25	25		0	25		25
H6622	071	0	1	01	01	H6622_071_0	2			Preferred Brand	4	11	1	2	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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	071	0	1	01	01	H6622_071_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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	25		25				25		25	25		25	25		25
H6622	071	0	1	01	01	H6622_071_0	2			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	25						25			25			25		25
H6622	071	0	1	01	01	H6622_071_0	2			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	0		0				0		0	0		0	0		0
H6622	075	0	1	01	01	H6622_075_0	2			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	0		0				25		25	0		0	0		0
H6622	075	0	1	01	01	H6622_075_0	2			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	0		0				25		25	0		0	0		0
H6622	075	0	1	01	01	H6622_075_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	075	0	1	01	01	H6622_075_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
H6622	075	0	1	01	01	H6622_075_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	25						25			25			25		25
H6622	078	1	1	01	01	H6622_078_1	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	0		0				25		25	0		0	0		0
H6622	078	1	1	01	01	H6622_078_1	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	0		0				25		25	0		0	0		0
H6622	078	1	1	01	01	H6622_078_1	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	078	1	1	01	01	H6622_078_1	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H6622	078	1	1	01	01	H6622_078_1	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	25						25			25			25		25
H6622	078	2	1	01	01	H6622_078_2	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	0		0				25		25	0		0	0		0
H6622	078	2	1	01	01	H6622_078_2	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	0		0				25		25	0		0	0		0
H6622	078	2	1	01	01	H6622_078_2	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	078	2	1	01	01	H6622_078_2	5		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H6622	078	2	1	01	01	H6622_078_2	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	25						25			25			25		25
H6622	079	0	1	01	01	H6622_079_0	5		N	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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
H6622	079	0	1	01	01	H6622_079_0	5		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
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				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	25		25				25		25	25		25	25		25
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					28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H6622	081	0	1	01	01	H6622_081_0	2			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	0		0				25		25	0		0	0		0
H6622	081	0	1	01	01	H6622_081_0	2			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	25		25				25		25	25		0	25		25
H6622	081	0	1	01	01	H6622_081_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	081	0	1	01	01	H6622_081_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				80.00	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	25		25				25		25	25		25	25		25
H6622	081	0	1	01	01	H6622_081_0	2			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	25						25			25			25		25
H6622	082	0	1	01	01	H6622_082_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	0		0				25		25	0		0	0		0
H6622	082	0	1	01	01	H6622_082_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	0		0				25		25	0		0	0		0
H6622	082	0	1	01	01	H6622_082_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	25		25				25		25	25		25	25		25
H6622	082	0	1	01	01	H6622_082_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H6622	082	0	1	01	01	H6622_082_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	25						25			25			25		25
H6622	083	0	1	01	01	H6622_083_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	0		0				25		25	0		0	0		0
H6622	083	0	1	01	01	H6622_083_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	083	0	1	01	01	H6622_083_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	25		25				25		25	25		25	25		25
H6622	083	0	1	01	01	H6622_083_0	3			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	25		25				25		25	25		25	25		25
H6622	083	0	1	01	01	H6622_083_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	25						25			25			25		25
H6622	084	0	1	01	01	H6622_084_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	0		0				25		25	0		0	0		0
H6622	084	0	1	01	01	H6622_084_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	25		25				25		25	25		0	25		25
H6622	084	0	1	01	01	H6622_084_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	084	0	1	01	01	H6622_084_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	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	25		25				25		25	25		25	25		25
H6622	084	0	1	01	01	H6622_084_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					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	25						25			25			25		25
H6622	084	0	1	01	01	H6622_084_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	0		0				0		0	0		0	0		0
H6622	085	0	1	01	01	H6622_085_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	0		0				25		25	0		0	0		0
H6622	085	0	1	01	01	H6622_085_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	085	0	1	01	01	H6622_085_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	25		25				25		25	25		25	25		25
H6622	085	0	1	01	01	H6622_085_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	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	25		25				25		25	25		25	25		25
H6622	085	0	1	01	01	H6622_085_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	25						25			25			25		25
H6622	087	0	1	01	01	H6622_087_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	0		0				25		25	0		0	0		0
H6622	087	0	1	01	01	H6622_087_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	0		0				25		25	0		0	0		0
H6622	087	0	1	01	01	H6622_087_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	087	0	1	01	01	H6622_087_0	5		N	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	25		25				25		25	25		25	25		25
H6622	087	0	1	01	01	H6622_087_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	25						25			25			25		25
H6622	090	0	1	01	01	H6622_090_0	2			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	0		0				25		25	0		0	0		0
H6622	090	0	1	01	01	H6622_090_0	2			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	0		0				25		25	0		0	0		0
H6622	090	0	1	01	01	H6622_090_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	090	0	1	01	01	H6622_090_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				98.00	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	25		25				25		25	25		25	25		25
H6622	090	0	1	01	01	H6622_090_0	2			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	25						25			25			25		25
H6622	091	0	1	01	01	H6622_091_0	2			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	0		0				25		25	0		0	0		0
H6622	091	0	1	01	01	H6622_091_0	2			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	0		0				25		25	0		0	0		0
H6622	091	0	1	01	01	H6622_091_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	091	0	1	01	01	H6622_091_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				83.00	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	25		25				25		25	25		25	25		25
H6622	091	0	1	01	01	H6622_091_0	2			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	25						25			25			25		25
H6622	095	0	1	01	01	H6622_095_0	2			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	0		0				25		25	0		0	0		0
H6622	095	0	1	01	01	H6622_095_0	2			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	25		25				25		25	25		0	25		25
H6622	095	0	1	01	01	H6622_095_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	095	0	1	01	01	H6622_095_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				85.00	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	25		25				25		25	25		25	25		25
H6622	095	0	1	01	01	H6622_095_0	2			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	25						25			25			25		25
H6622	097	0	1	01	01	H6622_097_0	2			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	0		0				25		25	0		0	0		0
H6622	097	0	1	01	01	H6622_097_0	2			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	25		25				25		25	25		0	25		25
H6622	097	0	1	01	01	H6622_097_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H6622	097	0	1	01	01	H6622_097_0	2			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	25		25				25		25	25		25	25		25
H6622	097	0	1	01	01	H6622_097_0	2			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	25						25			25			25		25
H6622	098	0	1	01	01	H6622_098_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	0		0				25		25	0		0	0		0
H6622	098	0	1	01	01	H6622_098_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	25		25				25		25	25		0	25		25
H6622	098	0	1	01	01	H6622_098_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	098	0	1	01	01	H6622_098_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	098	0	1	01	01	H6622_098_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	25						25			25			25		25
H6622	098	0	1	01	01	H6622_098_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	0		0				0		0	0		0	0		0
H6622	099	1	1	01	01	H6622_099_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	0		0				25		25	0		0	0		0
H6622	099	1	1	01	01	H6622_099_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	099	1	1	01	01	H6622_099_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	25		25				25		25	25		25	25		25
H6622	099	1	1	01	01	H6622_099_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H6622	099	1	1	01	01	H6622_099_1	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	25						25			25			25		25
H6622	099	2	1	01	01	H6622_099_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	0		0				25		25	0		0	0		0
H6622	099	2	1	01	01	H6622_099_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	099	2	1	01	01	H6622_099_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	25		25				25		25	25		25	25		25
H6622	099	2	1	01	01	H6622_099_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H6622	099	2	1	01	01	H6622_099_2	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	25						25			25			25		25
H6622	100	1	1	01	01	H6622_100_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	0		0				25		25	0		0	0		0
H6622	100	1	1	01	01	H6622_100_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																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	100	1	1	01	01	H6622_100_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	25		25				25		25	25		25	25		25
H6622	100	1	1	01	01	H6622_100_1	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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	25		25				25		25	25		25	25		25
H6622	100	1	1	01	01	H6622_100_1	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	25						25			25			25		25
H6622	100	2	1	01	01	H6622_100_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	0		0				25		25	0		0	0		0
H6622	100	2	1	01	01	H6622_100_2	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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H6622	100	2	1	01	01	H6622_100_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	25		25				25		25	25		25	25		25
H6622	100	2	1	01	01	H6622_100_2	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				92.00	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	25		25				25		25	25		25	25		25
H6622	100	2	1	01	01	H6622_100_2	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	25						25			25			25		25
H6622	101	0	1	01	01	H6622_101_0	4		N	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	0		0				25		25	0		0	0		0
H6622	101	0	1	01	01	H6622_101_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	0		0				25		25	0		0	0		0
H6622	101	0	1	01	01	H6622_101_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	101	0	1	01	01	H6622_101_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H6622	101	0	1	01	01	H6622_101_0	4		N	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	25						25			25			25		25
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	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																														
H6672	003	0	1	01	01	H6672_003_0	8			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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6672	003	0	1	01	01	H6672_003_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											51.99	20	20	20				51.99	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H6672	003	0	1	01	01	H6672_003_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											85.90	35	35	35				85.90	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											897.00	29						897.00	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H6672	003	0	1	01	01	H6672_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	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																														
H6672	005	0	1	01	01	H6672_005_0	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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6672	005	0	1	01	01	H6672_005_0	9			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											54.60	20	20	20				54.60	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H6672	005	0	1	01	01	H6672_005_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											82.65	34	34	34				82.65	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											835.57	28						835.57	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H6672	005	0	1	01	01	H6672_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6706	001	0	1	02	01	H6706_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6706	001	0	1	02	01	H6706_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6706	001	0	1	02	01	H6706_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H6706	001	0	1	02	01	H6706_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				84.00	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	25						25			25			25		25
H6706	001	0	1	02	01	H6706_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				409.00	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	25						25			25			25		25
H6723	001	1	1	01	01	H6723_001_1	14			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, Select Care Drugs																														
H6723	001	1	1	01	01	H6723_001_1	14			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, Select Care Drugs																														
H6723	001	1	1	01	01	H6723_001_1	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.09	21	21	21				44.20	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H6723	001	1	1	01	01	H6723_001_1	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.62	41	41	41				60.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	001	1	1	01	01	H6723_001_1	14			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																														
H6723	001	1	1	01	01	H6723_001_1	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	001	3	1	01	01	H6723_001_3	14			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, Select Care Drugs																														
H6723	001	3	1	01	01	H6723_001_3	14			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, Select Care Drugs																														
H6723	001	3	1	01	01	H6723_001_3	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.09	21	21	21				44.20	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	21	21	21	21	21	21	21	21	21	21	21	21	21		21
H6723	001	3	1	01	01	H6723_001_3	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.62	41	41	41				60.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	001	3	1	01	01	H6723_001_3	14			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																														
H6723	001	3	1	01	01	H6723_001_3	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	002	1	1	01	01	H6723_002_1	14			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	14.00					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, Select Care Drugs																														
H6723	002	1	1	01	01	H6723_002_1	14			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				5.00	10.00	10.00				12.00				12.00			0.40	0.17		0.37	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	002	1	1	01	01	H6723_002_1	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.85	24	24	24				42.32	24	24	24										24	24	24				24	24	24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H6723	002	1	1	01	01	H6723_002_1	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.15	40	40	40				46.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	002	1	1	01	01	H6723_002_1	14			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, Select Care Drugs																														
H6723	002	1	1	01	01	H6723_002_1	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	002	3	1	01	01	H6723_002_3	14			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	14.00					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, Select Care Drugs																														
H6723	002	3	1	01	01	H6723_002_3	14			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				5.00	10.00	10.00				12.00				12.00			0.40	0.17		0.37	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	002	3	1	01	01	H6723_002_3	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.85	24	24	24				42.32	24	24	24										24	24	24				24	24	24			24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H6723	002	3	1	01	01	H6723_002_3	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											41.15	40	40	40				46.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	002	3	1	01	01	H6723_002_3	14			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, Select Care Drugs																														
H6723	002	3	1	01	01	H6723_002_3	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	003	1	1	01	01	H6723_003_1	14			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	14.00					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, Select Care Drugs																														
H6723	003	1	1	01	01	H6723_003_1	14			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				5.00	10.00	10.00				12.00				12.00			0.40	0.17		0.37	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	003	1	1	01	01	H6723_003_1	14			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.94	23	23	23				40.64	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H6723	003	1	1	01	01	H6723_003_1	14			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.39	40	40	40				41.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	003	1	1	01	01	H6723_003_1	14			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, Select Care Drugs																														
H6723	003	1	1	01	01	H6723_003_1	14			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	003	3	1	01	01	H6723_003_3	16			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	14.00					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, Select Care Drugs																														
H6723	003	3	1	01	01	H6723_003_3	16			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				5.00	10.00	10.00				12.00				12.00			0.40	0.17		0.37	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	003	3	1	01	01	H6723_003_3	16			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.94	23	23	23				40.64	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H6723	003	3	1	01	01	H6723_003_3	16			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.39	40	40	40				41.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	003	3	1	01	01	H6723_003_3	16			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, Select Care Drugs																														
H6723	003	3	1	01	01	H6723_003_3	16			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	006	6	1	02	01	H6723_006_6	15			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	15.00					0.00	0.00	0.00											6.00	12.00	14.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	006	6	1	02	01	H6723_006_6	15			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	20.00					0.00	0.00	0.00											8.00	16.00	19.00				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																														
H6723	006	6	1	02	01	H6723_006_6	15			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.60	23	23	23				48.85	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H6723	006	6	1	02	01	H6723_006_6	15			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.61	40	40	40				54.04	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H6723	006	6	1	02	01	H6723_006_6	15			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																														
H6723	006	6	1	02	01	H6723_006_6	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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6723	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								6.00	12.00	15.00					0.00	0.00	0.00											6.00	12.00	14.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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								8.00	16.00	20.00					0.00	0.00	0.00											8.00	16.00	19.00				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																														
H6723	006	7	1	02	01	H6723_006_7	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											44.60	23	23	23				48.85	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
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											46.61	40	40	40				54.04	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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												29							29												29						29					29			29								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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			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	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	001	0	1	04	01	H6743_001_0	7			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	10.00		20.00																					20.00																10.00				10.00		0.32						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	10.00		20.00						20.00				10.00		10.00	25		25						25				25		25
H6743	001	0	1	04	01	H6743_001_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	001	0	1	04	01	H6743_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	001	0	1	04	01	H6743_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				470.43	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	001	0	1	04	01	H6743_001_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	007	0	1	04	01	H6743_007_0	10			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	10			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	10.00		20.00																					20.00																10.00				10.00		0.32						0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	10.00		20.00						20.00				10.00		10.00	25		25						25				25		25
H6743	007	0	1	04	01	H6743_007_0	10			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	25		25						25				25		25
H6743	007	0	1	04	01	H6743_007_0	10			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	25		25						25				25		25
H6743	007	0	1	04	01	H6743_007_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				505.64	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	007	0	1	04	01	H6743_007_0	10			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	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	025	0	1	04	01	H6743_025_0	7			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H6743	025	0	1	04	01	H6743_025_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	025	0	1	04	01	H6743_025_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	025	0	1	04	01	H6743_025_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				505.81	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	025	0	1	04	01	H6743_025_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	026	0	1	04	01	H6743_026_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	026	0	1	04	01	H6743_026_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H6743	026	0	1	04	01	H6743_026_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	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	25		25						25				25		25
H6743	026	0	1	04	01	H6743_026_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	60.00		120.00																					120.00																60.00				60.00		1.94						1.76	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	026	0	1	04	01	H6743_026_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				395.96	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	026	0	1	04	01	H6743_026_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	028	0	1	04	01	H6743_028_0	9			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	028	0	1	04	01	H6743_028_0	9			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H6743	028	0	1	04	01	H6743_028_0	9			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	028	0	1	04	01	H6743_028_0	9			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H6743	028	0	1	04	01	H6743_028_0	9			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				379.29	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	028	0	1	04	01	H6743_028_0	9			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6743	030	0	1	04	01	H6743_030_0	8			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	8			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	25		25						25				25		25
H6743	030	0	1	04	01	H6743_030_0	8			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	25		25						25				25		25
H6743	030	0	1	04	01	H6743_030_0	8			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	25		25						25				25		25
H6743	030	0	1	04	01	H6743_030_0	8			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				423.93	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	8			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	0	0	0				0	0	0				0		0
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	25	25	25				25	25	25				25		25
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				67.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H6815	038	0	1	02	01	H6815_038_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6815	038	0	1	02	01	H6815_038_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6815	038	0	1	02	01	H6815_038_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											107.69	25	25	25				107.69	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	038	0	1	02	01	H6815_038_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											67.21	36	36	36				65.34	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	038	0	1	02	01	H6815_038_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6815	038	0	1	02	01	H6815_038_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6815	039	0	1	02	01	H6815_039_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6815	039	0	1	02	01	H6815_039_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											124.78	25	25	25				124.78	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	039	0	1	02	01	H6815_039_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											72.54	32	32	32				72.54	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	039	0	1	02	01	H6815_039_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6815	039	0	1	02	01	H6815_039_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H6815	040	0	1	02	01	H6815_040_0	6			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H6815	040	0	1	02	01	H6815_040_0	6			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											119.83	25	25	25				119.83	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	040	0	1	02	01	H6815_040_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											71.61	50	50	50				71.61	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6815	040	0	1	02	01	H6815_040_0	6			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								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		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6824	001	0	1	04	01	H6824_001_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H6824	001	0	1	04	01	H6824_001_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6824	001	0	1	04	01	H6824_001_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				58.00	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	25		25						25				25		25
H6824	001	0	1	04	01	H6824_001_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				70.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6824	001	0	1	04	01	H6824_001_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				379.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6824	002	0	1	04	01	H6824_002_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H6824	002	0	1	04	01	H6824_002_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6824	002	0	1	04	01	H6824_002_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H6824	002	0	1	04	01	H6824_002_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				70.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6824	002	0	1	04	01	H6824_002_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				389.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6832	004	0	1	02	01	H6832_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	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																														
H6832	004	0	1	02	01	H6832_004_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 Drug, Specialty Tier																														
H6832	004	0	1	02	01	H6832_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6832	004	0	1	02	01	H6832_004_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6832	004	0	1	02	01	H6832_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 Drug, 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	25	25	25				25	25	25				25		25
H6847	001	0	1	02	01	H6847_001_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				85.60	25	25	25																		25	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	25	25	25				25	25	25				25		25
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				1269.20	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6851	002	0	1	01	01	H6851_002_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H6851	002	0	1	01	01	H6851_002_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	10.00		25.00																			0.00		0.00																10.00				10.00		0.33			0.00			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		25.00				0.00		0.00				10.00		10.00	25		25				0		0				25		25
H6851	002	0	1	01	01	H6851_002_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		132.00																			45.00		130.00																47.00				47.00		1.57			1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00				35.00		35.00	25		25				25		25				25		25
H6851	002	0	1	01	01	H6851_002_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				1	2	30		90				30		31	100.00		280.00																			97.00		275.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00				35.00		35.00	25		25				25		25				25		25
H6851	002	0	1	01	01	H6851_002_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6851	003	0	1	01	01	H6851_003_0	8			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		90				1	2	30		90				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H6851	003	0	1	01	01	H6851_003_0	8			Generic	4	01	1	2	2	1	110		01	110		1	30		90				1	2	30		90				30		31	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	25		25				0		0				25		25
H6851	003	0	1	01	01	H6851_003_0	8			Preferred Brand	4	11	1	2	3	1	110		01	110		1	30		90				1	2	30		90				30		31	47.00		132.00																			45.00		130.00																47.00				47.00		1.57			1.50			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00				35.00		35.00	25		25				25		25				25		25
H6851	003	0	1	01	01	H6851_003_0	8			Non-Preferred Drug	4	11	1	2	4	1	110		01	110		1	30		90				1	2	30		90				30		31	100.00		280.00																			97.00		275.00																100.00				100.00		3.33			3.23			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00				35.00		35.00	25		25				25		25				25		25
H6851	003	0	1	01	01	H6851_003_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					27																				27																	27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6852	005	0	1	01	01	H6852_005_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H6852	005	0	1	01	01	H6852_005_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	005	0	1	01	01	H6852_005_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	005	0	1	01	01	H6852_005_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	005	0	1	01	01	H6852_005_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	005	0	1	01	01	H6852_005_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	007	0	1	01	01	H6852_007_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H6852	007	0	1	01	01	H6852_007_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	007	0	1	01	01	H6852_007_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	007	0	1	01	01	H6852_007_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	007	0	1	01	01	H6852_007_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	007	0	1	01	01	H6852_007_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	008	0	1	01	01	H6852_008_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	0	0	0				0	0	0				0		0
H6852	008	0	1	01	01	H6852_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	008	0	1	01	01	H6852_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				32.00	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	19	19	19				19	19	19				19		19
H6852	008	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	008	0	1	01	01	H6852_008_0	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	25						25						25		25
H6852	009	0	1	01	01	H6852_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	009	0	1	01	01	H6852_009_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	25	25	25				25	25	25				25		25
H6852	009	0	1	01	01	H6852_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				39.00	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	21	21	21				21	21	21				21		21
H6852	009	0	1	01	01	H6852_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	009	0	1	01	01	H6852_009_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	25						25						25		25
H6852	010	0	1	01	01	H6852_010_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	0	0	0				0	0	0				0		0
H6852	010	0	1	01	01	H6852_010_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	010	0	1	01	01	H6852_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				32.00	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	19	19	19				19	19	19				19		19
H6852	010	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	010	0	1	01	01	H6852_010_0	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	25						25						25		25
H6852	011	0	1	01	01	H6852_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	011	0	1	01	01	H6852_011_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	25	25	25				25	25	25				25		25
H6852	011	0	1	01	01	H6852_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				39.00	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	21	21	21				21	21	21				21		21
H6852	011	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	011	0	1	01	01	H6852_011_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	25						25						25		25
H6852	012	0	1	01	01	H6852_012_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	0	0	0				0	0	0				0		0
H6852	012	0	1	01	01	H6852_012_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	012	0	1	01	01	H6852_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				32.00	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	19	19	19				19	19	19				19		19
H6852	012	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	012	0	1	01	01	H6852_012_0	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	25						25						25		25
H6852	013	0	1	01	01	H6852_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	0	0	0				0	0	0				0		0
H6852	013	0	1	01	01	H6852_013_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	25	25	25				25	25	25				25		25
H6852	013	0	1	01	01	H6852_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				39.00	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	21	21	21				21	21	21				21		21
H6852	013	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	013	0	1	01	01	H6852_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	25						25						25		25
H6852	014	0	1	01	01	H6852_014_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	0	0	0				0	0	0				0		0
H6852	014	0	1	01	01	H6852_014_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	014	0	1	01	01	H6852_014_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				32.00	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	19	19	19				19	19	19				19		19
H6852	014	0	1	01	01	H6852_014_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	014	0	1	01	01	H6852_014_0	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	25						25						25		25
H6852	015	0	1	01	01	H6852_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H6852	015	0	1	01	01	H6852_015_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	25	25	25				25	25	25				25		25
H6852	015	0	1	01	01	H6852_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				39.00	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	21	21	21				21	21	21				21		21
H6852	015	0	1	01	01	H6852_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				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	25	25	25				25	25	25				25		25
H6852	015	0	1	01	01	H6852_015_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	25						25						25		25
H6852	016	0	1	01	01	H6852_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	016	0	1	01	01	H6852_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6852	016	0	1	01	01	H6852_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H6852	016	0	1	01	01	H6852_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	016	0	1	01	01	H6852_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	016	0	1	01	01	H6852_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	017	0	1	01	01	H6852_017_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	017	0	1	01	01	H6852_017_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6852	017	0	1	01	01	H6852_017_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6852	017	0	1	01	01	H6852_017_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	017	0	1	01	01	H6852_017_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	017	0	1	01	01	H6852_017_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	018	0	1	01	01	H6852_018_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	018	0	1	01	01	H6852_018_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6852	018	0	1	01	01	H6852_018_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6852	018	0	1	01	01	H6852_018_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	018	0	1	01	01	H6852_018_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	018	0	1	01	01	H6852_018_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	019	0	1	01	01	H6852_019_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	019	0	1	01	01	H6852_019_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6852	019	0	1	01	01	H6852_019_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6852	019	0	1	01	01	H6852_019_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	019	0	1	01	01	H6852_019_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	019	0	1	01	01	H6852_019_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	020	0	1	01	01	H6852_020_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	020	0	1	01	01	H6852_020_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6852	020	0	1	01	01	H6852_020_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6852	020	0	1	01	01	H6852_020_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	020	0	1	01	01	H6852_020_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	020	0	1	01	01	H6852_020_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	021	0	1	01	01	H6852_021_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	021	0	1	01	01	H6852_021_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H6852	021	0	1	01	01	H6852_021_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	021	0	1	01	01	H6852_021_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H6852	021	0	1	01	01	H6852_021_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	021	0	1	01	01	H6852_021_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	022	0	1	01	01	H6852_022_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6852	022	0	1	01	01	H6852_022_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H6852	022	0	1	01	01	H6852_022_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	022	0	1	01	01	H6852_022_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H6852	022	0	1	01	01	H6852_022_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	022	0	1	01	01	H6852_022_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	023	0	1	01	01	H6852_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6852	023	0	1	01	01	H6852_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																			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	25	25	25				25	25	25				25		25
H6852	023	0	1	01	01	H6852_023_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H6852	023	0	1	01	01	H6852_023_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	023	0	1	01	01	H6852_023_0	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	25						25						25		25
H6852	025	0	1	01	01	H6852_025_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H6852	025	0	1	01	01	H6852_025_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	025	0	1	01	01	H6852_025_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	025	0	1	01	01	H6852_025_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	025	0	1	01	01	H6852_025_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	025	0	1	01	01	H6852_025_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6852	026	0	1	01	01	H6852_026_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H6852	026	0	1	01	01	H6852_026_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	026	0	1	01	01	H6852_026_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	026	0	1	01	01	H6852_026_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6852	026	0	1	01	01	H6852_026_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6852	026	0	1	01	01	H6852_026_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	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																														
H6874	001	0	1	04	01	H6874_001_0	9			Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					29	31				59.00	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	70.00				35.00		35.00	20	20	20				20	20	20				20		20
H6874	001	0	1	04	01	H6874_001_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				26.00	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	25	25	25				25	25	25				25		25
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				1750.00	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6876	001	0	1	04	01	H6876_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	0	0	0				0	0	0				0		0
H6876	001	0	1	04	01	H6876_001_0	9			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	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6876	001	0	1	04	01	H6876_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				65.56	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	25	25	25				25	25	25				25		25
H6876	001	0	1	04	01	H6876_001_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1072.23	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H6876	003	0	1	04	01	H6876_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	0	0	0				0	0	0				0		0
H6876	003	0	1	04	01	H6876_003_0	9			Generic	4	11	3	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			0.00	0.00	0.00																5.00				5.00		0.17			0.00			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6876	003	0	1	04	01	H6876_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	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	0	0	0				0	0	0				0		0
H6876	003	0	1	04	01	H6876_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				124.05	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H6876	003	0	1	04	01	H6876_003_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				924.36	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						0						0		0
H6876	003	0	1	04	01	H6876_003_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6876	004	0	1	04	01	H6876_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	0	0	0				0	0	0				0		0
H6876	004	0	1	04	01	H6876_004_0	9			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	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6876	004	0	1	04	01	H6876_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				63.75	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	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H6876	004	0	1	04	01	H6876_004_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				975.38	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
H6876	005	0	1	04	01	H6876_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	0	0	0				0	0	0				0		0
H6876	005	0	1	04	01	H6876_005_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																														
H6876	005	0	1	04	01	H6876_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	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	0	0	0				0	0	0				0		0
H6876	005	0	1	04	01	H6876_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				104.58	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H6876	005	0	1	04	01	H6876_005_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				948.31	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						0						0		0
H6876	005	0	1	04	01	H6876_005_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H6876	007	0	1	04	01	H6876_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	0	0	0				0	0	0				0		0
H6876	007	0	1	04	01	H6876_007_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																														
H6876	007	0	1	04	01	H6876_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	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	0	0	0				0	0	0				0		0
H6876	007	0	1	04	01	H6876_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				128.14	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H6876	007	0	1	04	01	H6876_007_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				866.33	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						0						0		0
H6876	007	0	1	04	01	H6876_007_0	8			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H6876	009	0	1	04	01	H6876_009_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	0	0	0				0	0	0				0		0
H6876	009	0	1	04	01	H6876_009_0	9			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	9			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			47.00	94.00	94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6876	009	0	1	04	01	H6876_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				78.51	25	25	25																		25	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	25	25	25				25	25	25				25		25
H6876	009	0	1	04	01	H6876_009_0	9			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1125.17	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00						0.00						0.00		0.00	0						0						0		0
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	25	25	25	0	0	0	0	0	0				25		25
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					2.00	4.00	6.00					0.00	0.00	0.00																20.00				20.00			0.67	0.07	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	2.00	4.00	6.00	0.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	0	0	0				25		25
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											36.14	25	25	25				42.48	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-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	25	25	25	25	25	25	25	25	25				25		25
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											68.29	35	35	35				70.55	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	25	25	25	25	25	25	25	25	25				25		25
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												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
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	25	25	25	0	0	0	0	0	0				25		25
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					2.00	4.00	6.00					0.00	0.00	0.00																20.00				20.00			0.67	0.07	0.00			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	2.00	4.00	6.00	0.00	0.00	0.00				20.00		20.00	25	25	25	25	25	25	0	0	0				25		25
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											40.15	25	25	25				48.54	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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											71.52	35	35	35				70.62	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H6959	002	0	1	01	01	H6959_002_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 Drug, Specialty Tier																														
H6959	002	0	1	01	01	H6959_002_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 Drug, Specialty Tier																														
H6959	002	0	1	01	01	H6959_002_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6959	002	0	1	01	01	H6959_002_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6959	002	0	1	01	01	H6959_002_0	6			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				750.55	29																				29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6971	001	0	1	01	01	H6971_001_0	7		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6971	001	0	1	01	01	H6971_001_0	7		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6971	001	0	1	01	01	H6971_001_0	7		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.81	20	20	20				78.81	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H6971	001	0	1	01	01	H6971_001_0	7		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H6971	001	0	1	01	01	H6971_001_0	7		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6971	001	0	1	01	01	H6971_001_0	7		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6988	004	0	1	01	01	H6988_004_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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																														
H6988	004	0	1	01	01	H6988_004_0	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6988	004	0	1	01	01	H6988_004_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				96.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6988	004	0	1	01	01	H6988_004_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				45.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6988	004	0	1	01	01	H6988_004_0	7		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																														
H6988	004	0	1	01	01	H6988_004_0	7		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																														
H6988	006	0	1	02	01	H6988_006_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																														
H6988	006	0	1	02	01	H6988_006_0	5			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																														
H6988	006	0	1	02	01	H6988_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											80.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6988	006	0	1	02	01	H6988_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											26.00	30	30	30				19.00	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	25	25	25	25	25	25	25	25	25				25		25
H6988	006	0	1	02	01	H6988_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6988	007	0	1	02	01	H6988_007_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																														
H6988	007	0	1	02	01	H6988_007_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6988	007	0	1	02	01	H6988_007_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6988	007	0	1	02	01	H6988_007_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											25.00	30	30	30				19.00	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	25	25	25	25	25	25	25	25	25				25		25
H6988	007	0	1	02	01	H6988_007_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6988	009	0	1	02	01	H6988_009_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																														
H6988	009	0	1	02	01	H6988_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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6988	009	0	1	02	01	H6988_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											86.00	25	25	25				121.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6988	009	0	1	02	01	H6988_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											28.00	30	30	30				21.00	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	25	25	25	25	25	25	25	25	25				25		25
H6988	009	0	1	02	01	H6988_009_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																														
H6988	010	0	1	02	01	H6988_010_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																														
H6988	010	0	1	02	01	H6988_010_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6988	010	0	1	02	01	H6988_010_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											86.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H6988	010	0	1	02	01	H6988_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											28.00	30	30	30				20.00	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	25	25	25	25	25	25	25	25	25				25		25
H6988	010	0	1	02	01	H6988_010_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H6994	001	0	1	01	01	H6994_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	0	0	0				0	0	0				0		0
H6994	001	0	1	01	01	H6994_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6994	001	0	1	01	01	H6994_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				32.00	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	19	19	19				19	19	19				19		19
H6994	001	0	1	01	01	H6994_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	001	0	1	01	01	H6994_001_0	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	25						25						25		25
H6994	002	0	1	01	01	H6994_002_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	0	0	0				0	0	0				0		0
H6994	002	0	1	01	01	H6994_002_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	25	25	25				25	25	25				25		25
H6994	002	0	1	01	01	H6994_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				39.00	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	21	21	21				21	21	21				21		21
H6994	002	0	1	01	01	H6994_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				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	25	25	25				25	25	25				25		25
H6994	002	0	1	01	01	H6994_002_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	25						25						25		25
H6994	003	0	1	01	01	H6994_003_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6994	003	0	1	01	01	H6994_003_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6994	003	0	1	01	01	H6994_003_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6994	003	0	1	01	01	H6994_003_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	003	0	1	01	01	H6994_003_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6994	003	0	1	01	01	H6994_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6994	004	0	1	01	01	H6994_004_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6994	004	0	1	01	01	H6994_004_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H6994	004	0	1	01	01	H6994_004_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	004	0	1	01	01	H6994_004_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H6994	004	0	1	01	01	H6994_004_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6994	004	0	1	01	01	H6994_004_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6994	008	0	1	01	01	H6994_008_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	0	0	0				0	0	0				0		0
H6994	008	0	1	01	01	H6994_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6994	008	0	1	01	01	H6994_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				32.00	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	19	19	19				19	19	19				19		19
H6994	008	0	1	01	01	H6994_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				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	25	25	25				25	25	25				25		25
H6994	008	0	1	01	01	H6994_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H6994	009	0	1	01	01	H6994_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6994	009	0	1	01	01	H6994_009_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	25	25	25				25	25	25				25		25
H6994	009	0	1	01	01	H6994_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				39.00	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	21	21	21				21	21	21				21		21
H6994	009	0	1	01	01	H6994_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				64.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	009	0	1	01	01	H6994_009_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	25						25						25		25
H6994	010	0	1	01	01	H6994_010_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6994	010	0	1	01	01	H6994_010_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6994	010	0	1	01	01	H6994_010_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H6994	010	0	1	01	01	H6994_010_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	010	0	1	01	01	H6994_010_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6994	010	0	1	01	01	H6994_010_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H6994	011	0	1	01	01	H6994_011_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	0	0	0				0	0	0				0		0
H6994	011	0	1	01	01	H6994_011_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6994	011	0	1	01	01	H6994_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				32.00	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	19	19	19				19	19	19				19		19
H6994	011	0	1	01	01	H6994_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	011	0	1	01	01	H6994_011_0	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	25						25						25		25
H6994	012	0	1	01	01	H6994_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H6994	012	0	1	01	01	H6994_012_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	25	25	25				25	25	25				25		25
H6994	012	0	1	01	01	H6994_012_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	21	21	21				21	21	21				21		21
H6994	012	0	1	01	01	H6994_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				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	25	25	25				25	25	25				25		25
H6994	012	0	1	01	01	H6994_012_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	25						25						25		25
H6994	013	0	1	01	01	H6994_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H6994	013	0	1	01	01	H6994_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																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H6994	013	0	1	01	01	H6994_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H6994	013	0	1	01	01	H6994_013_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H6994	013	0	1	01	01	H6994_013_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H6994	013	0	1	01	01	H6994_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7006	007	0	1	04	01	H7006_007_0	7			Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7006	007	0	1	04	01	H7006_007_0	7			Generic	4	01	3	2	2	1	110		01	100		1	31		100				1	2			100				31		34	8.00		16.00																					16.00																8.00				8.00		0.26						0.24	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	8.00		16.00						16.00				8.00		8.00	25		25						25				25		25
H7006	007	0	1	04	01	H7006_007_0	7			Preferred Brand	4	10	1	2	3	1	110		01	100		1	31		100				1	2			100				31		34	47.00		94.00																					94.00																47.00				47.00		1.52						1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						70.00				35.00		35.00	25		25						25				25		25
H7006	007	0	1	04	01	H7006_007_0	7			Non-Preferred Drug	4	11	1	2	4	1	110		01	100		1	31		100				1	2			100				31		34	100.00		200.00																					200.00																100.00				100.00		3.23						2.94	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		70.00						35.00				35.00		35.00	25		25						25				25		25
H7006	007	0	1	04	01	H7006_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				408.19	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7006	007	0	1	04	01	H7006_007_0	7			Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				1	2			100				31		34	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7006	018	0	1	04	01	H7006_018_0	10			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	10			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	25		25						25				25		25
H7006	018	0	1	04	01	H7006_018_0	10			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	25		25						25				25		25
H7006	018	0	1	04	01	H7006_018_0	10			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	25		25						25				25		25
H7006	018	0	1	04	01	H7006_018_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				536.63	28																																					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7006	018	0	1	04	01	H7006_018_0	10			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	10			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	10			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	25		25						25				25		25
H7006	022	0	1	04	01	H7006_022_0	10			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	25		25						25				25		25
H7006	022	0	1	04	01	H7006_022_0	10			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	25		25						25				25		25
H7006	022	0	1	04	01	H7006_022_0	10			Specialty Tier	4	11	1	1	5	1	010		01	000		1	31														31		34				608.71	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	10			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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	010	1	1	01	01	H7020_010_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	010	1	1	01	01	H7020_010_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	1	1	01	01	H7020_010_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											44.73	50	50	50				42.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	1	1	01	01	H7020_010_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											548.94	33						572.31	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7020	010	2	1	01	01	H7020_010_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	010	2	1	01	01	H7020_010_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	010	2	1	01	01	H7020_010_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	2	1	01	01	H7020_010_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											44.73	50	50	50				42.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	2	1	01	01	H7020_010_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											548.94	33						572.31	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7020	010	3	1	01	01	H7020_010_3	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	010	3	1	01	01	H7020_010_3	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	010	3	1	01	01	H7020_010_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	3	1	01	01	H7020_010_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											44.73	50	50	50				42.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	010	3	1	01	01	H7020_010_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											548.94	33						572.31	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7020	011	1	1	01	01	H7020_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	011	1	1	01	01	H7020_011_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	011	1	1	01	01	H7020_011_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	1	1	01	01	H7020_011_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											52.43	50	50	50				50.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	1	1	01	01	H7020_011_1	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.02	28						444.44	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7020	011	2	1	01	01	H7020_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	011	2	1	01	01	H7020_011_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					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	011	2	1	01	01	H7020_011_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	2	1	01	01	H7020_011_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											52.43	50	50	50				50.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	2	1	01	01	H7020_011_2	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.02	28						444.44	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7020	011	3	1	01	01	H7020_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								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7020	011	3	1	01	01	H7020_011_3	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7020	011	3	1	01	01	H7020_011_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	3	1	01	01	H7020_011_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											52.43	50	50	50				50.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7020	011	3	1	01	01	H7020_011_3	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											552.02	28						444.44	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7028	001	0	1	04	01	H7028_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	0	0	0				0	0	0				0		0
H7028	001	0	1	04	01	H7028_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7028	001	0	1	04	01	H7028_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				55.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7028	001	0	1	04	01	H7028_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				83.00	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		35.00	25	25	25				25	25	25				25		25
H7028	001	0	1	04	01	H7028_001_0	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	25						25						25		25
H7028	002	0	1	04	01	H7028_002_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	0	0	0				0	0	0				0		0
H7028	002	0	1	04	01	H7028_002_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	25	25	25				25	25	25				25		25
H7028	002	0	1	04	01	H7028_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				54.00	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	22	22	22				22	22	22				22		22
H7028	002	0	1	04	01	H7028_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				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	25	25	25				25	25	25				25		25
H7028	002	0	1	04	01	H7028_002_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	25						25						25		25
H7028	004	0	1	04	01	H7028_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	0	0	0				0	0	0				0		0
H7028	004	0	1	04	01	H7028_004_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7028	004	0	1	04	01	H7028_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				32.00	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	20	20	20				20	20	20				20		20
H7028	004	0	1	04	01	H7028_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				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	25	25	25				25	25	25				25		25
H7028	004	0	1	04	01	H7028_004_0	6			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	25						25						25		25
H7028	005	0	1	04	01	H7028_005_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7028	005	0	1	04	01	H7028_005_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7028	005	0	1	04	01	H7028_005_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7028	005	0	1	04	01	H7028_005_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7028	005	0	1	04	01	H7028_005_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7028	005	0	1	04	01	H7028_005_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7028	006	0	1	04	01	H7028_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7028	006	0	1	04	01	H7028_006_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7028	006	0	1	04	01	H7028_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7028	006	0	1	04	01	H7028_006_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7028	006	0	1	04	01	H7028_006_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7028	006	0	1	04	01	H7028_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7063	001	0	1	04	01	H7063_001_0	3			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	001	0	1	04	01	H7063_001_0	3			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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	001	0	1	04	01	H7063_001_0	3			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											67.14	25	25	25				63.91	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	001	0	1	04	01	H7063_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											78.05	33	33	33				73.66	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	001	0	1	04	01	H7063_001_0	3			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											686.86	29						624.88	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7063	006	0	1	04	01	H7063_006_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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	006	0	1	04	01	H7063_006_0	5			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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	006	0	1	04	01	H7063_006_0	5			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											68.03	25	25	25				62.17	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	006	0	1	04	01	H7063_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											90.66	33	33	33				86.27	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	006	0	1	04	01	H7063_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											609.32	29						721.44	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7063	007	0	1	04	01	H7063_007_0	3			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	007	0	1	04	01	H7063_007_0	3			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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	007	0	1	04	01	H7063_007_0	3			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											65.36	25	25	25				61.88	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	007	0	1	04	01	H7063_007_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											85.93	33	33	33				79.87	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	007	0	1	04	01	H7063_007_0	3			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											718.28	29						689.42	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7063	012	0	1	04	01	H7063_012_0	3			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	012	0	1	04	01	H7063_012_0	3			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					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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7063	012	0	1	04	01	H7063_012_0	3			Preferred Brand	4	10	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											70.58	25	25	25				64.03	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	012	0	1	04	01	H7063_012_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											94.64	33	33	33				83.66	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
H7063	012	0	1	04	01	H7063_012_0	3			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											550.04	29						521.29	29																							29			29								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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
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	25	25	25				25	25	25				25		25
H7074	001	0	1	04	01	H7074_001_0	8			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				40.85	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		35.00	25	25	25				25	25	25				25		25
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				548.85	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	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																														
H7093	002	0	1	04	01	H7093_002_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								14.00	28.00	42.00					9.00	18.00	27.00					0.00	0.00	0.00																14.00				14.00			0.47	0.30	0.00			0.41	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7093	002	0	1	04	01	H7093_002_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											43.00	25	25	25				57.00	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	25	25	25	20	20	20	20	20	20				25		25
H7093	002	0	1	04	01	H7093_002_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											30.00	35	35	35				20.00	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	25	25	25	25	25	25	25	25	25				25		25
H7093	002	0	1	04	01	H7093_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												31							31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7093	002	0	1	04	01	H7093_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	8			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7115	001	0	1	01	01	H7115_001_0	8			Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	5.00	10.00	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	25	25	25				25	25	25				25		25
H7115	001	0	1	01	01	H7115_001_0	8			Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				54.86	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	23	23	23				23	23	23				23		23
H7115	001	0	1	01	01	H7115_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				77.54	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	25	25	25				25	25	25				25		25
H7115	001	0	1	01	01	H7115_001_0	8			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				410.18	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7123	001	0	1	01	01	H7123_001_0	17		N	Preferred Generic	2	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7123	001	0	1	01	01	H7123_001_0	17		N	Generic	2	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	0	0	0				0	0	0				0		0
H7123	001	0	1	01	01	H7123_001_0	17		N	Preferred Brand	2	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				41.29	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7123	001	0	1	01	01	H7123_001_0	17		N	Non-Preferred Drug	2	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				43.94	50	50	50																		50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7123	001	0	1	01	01	H7123_001_0	17		N	Specialty Tier	2	11	1	1	5	1	010		01	010		1	30								30						30		31				738.42	25																				25																	25			25								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	0	0	0				0	0	0				0		0
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	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	25	25	25				25	25	25				25		25
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				62.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7147	003	0	1	01	01	H7147_003_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7147	003	0	1	01	01	H7147_003_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	003	0	1	01	01	H7147_003_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				63.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	003	0	1	01	01	H7147_003_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	003	0	1	01	01	H7147_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	003	0	1	01	01	H7147_003_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	004	0	1	01	01	H7147_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7147	004	0	1	01	01	H7147_004_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	0	0	0				0	0	0				0		0
H7147	004	0	1	01	01	H7147_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				62.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7147	004	0	1	01	01	H7147_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				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	25	25	25				25	25	25				25		25
H7147	004	0	1	01	01	H7147_004_0	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	25						25						25		25
H7147	007	0	1	01	01	H7147_007_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7147	007	0	1	01	01	H7147_007_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	007	0	1	01	01	H7147_007_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				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	007	0	1	01	01	H7147_007_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				66.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	007	0	1	01	01	H7147_007_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	007	0	1	01	01	H7147_007_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	009	0	1	01	01	H7147_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7147	009	0	1	01	01	H7147_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																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7147	009	0	1	01	01	H7147_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H7147	009	0	1	01	01	H7147_009_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	009	0	1	01	01	H7147_009_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	009	0	1	01	01	H7147_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	010	0	1	01	01	H7147_010_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7147	010	0	1	01	01	H7147_010_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7147	010	0	1	01	01	H7147_010_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H7147	010	0	1	01	01	H7147_010_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	010	0	1	01	01	H7147_010_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	010	0	1	01	01	H7147_010_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	011	0	1	01	01	H7147_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7147	011	0	1	01	01	H7147_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																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7147	011	0	1	01	01	H7147_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H7147	011	0	1	01	01	H7147_011_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	011	0	1	01	01	H7147_011_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	011	0	1	01	01	H7147_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	012	0	1	01	01	H7147_012_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7147	012	0	1	01	01	H7147_012_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	012	0	1	01	01	H7147_012_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				48.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	012	0	1	01	01	H7147_012_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				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	012	0	1	01	01	H7147_012_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	012	0	1	01	01	H7147_012_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7147	013	0	1	01	01	H7147_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7147	013	0	1	01	01	H7147_013_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7147	013	0	1	01	01	H7147_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7147	013	0	1	01	01	H7147_013_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7147	013	0	1	01	01	H7147_013_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7147	013	0	1	01	01	H7147_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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											72.87	24	24	24				91.71	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.46	25	25	25				42.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											473.11	25						575.00	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	25			25			25			25			25		25
H7149	006	0	1	01	01	H7149_006_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7149	006	0	1	01	01	H7149_006_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7149	006	0	1	01	01	H7149_006_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				60.95	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	22	22	22				22	22	22				22		22
H7149	006	0	1	01	01	H7149_006_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				33.11	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7149	006	0	1	01	01	H7149_006_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				416.40	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7151	001	0	1	01	01	H7151_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	0	0	0				0	0	0				0		0
H7151	001	0	1	01	01	H7151_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7151	001	0	1	01	01	H7151_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				37.00	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		35.00	23	23	23				23	23	23				23		23
H7151	001	0	1	01	01	H7151_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				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	25	25	25				25	25	25				25		25
H7151	001	0	1	01	01	H7151_001_0	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	25						25						25		25
H7151	003	0	1	01	01	H7151_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	0	0	0				0	0	0				0		0
H7151	003	0	1	01	01	H7151_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	25	25	25				25	25	25				25		25
H7151	003	0	1	01	01	H7151_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				41.00	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	21	21	21				21	21	21				21		21
H7151	003	0	1	01	01	H7151_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				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	25	25	25				25	25	25				25		25
H7151	003	0	1	01	01	H7151_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	25						25						25		25
H7151	005	0	1	01	01	H7151_005_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7151	005	0	1	01	01	H7151_005_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7151	005	0	1	01	01	H7151_005_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H7151	005	0	1	01	01	H7151_005_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7151	005	0	1	01	01	H7151_005_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7151	005	0	1	01	01	H7151_005_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7151	006	0	1	01	01	H7151_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7151	006	0	1	01	01	H7151_006_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7151	006	0	1	01	01	H7151_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7151	006	0	1	01	01	H7151_006_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7151	006	0	1	01	01	H7151_006_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7151	006	0	1	01	01	H7151_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7199	002	0	1	04	01	H7199_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	0	0	0				0	0	0				0		0
H7199	002	0	1	04	01	H7199_002_0	6			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	25	25	25				25	25	25				25		25
H7199	002	0	1	04	01	H7199_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				50.00	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	22	22	22				22	22	22				22		22
H7199	002	0	1	04	01	H7199_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				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	25	25	25				25	25	25				25		25
H7199	002	0	1	04	01	H7199_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	25						25						25		25
H7220	004	0	1	02	01	H7220_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																														
H7220	004	0	1	02	01	H7220_004_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																														
H7220	004	0	1	02	01	H7220_004_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											67.14	25	25	25				66.70	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H7220	004	0	1	02	01	H7220_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											56.15	35	35	35				54.71	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	25	25	25	25	25	25	25	25	25				25		25
H7220	004	0	1	02	01	H7220_004_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																														
H7220	004	0	1	02	01	H7220_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																														
H7220	009	1	1	01	01	H7220_009_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																														
H7220	009	1	1	01	01	H7220_009_1	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																														
H7220	009	1	1	01	01	H7220_009_1	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.17	25	25	25				69.70	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H7220	009	1	1	01	01	H7220_009_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											48.71	35	35	35				51.43	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	25	25	25	25	25	25	25	25	25				25		25
H7220	009	1	1	01	01	H7220_009_1	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																														
H7220	009	1	1	01	01	H7220_009_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																														
H7220	009	2	1	01	01	H7220_009_2	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																														
H7220	009	2	1	01	01	H7220_009_2	5			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																														
H7220	009	2	1	01	01	H7220_009_2	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											72.17	25	25	25				69.70	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	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	90	2	2	30	60	90				30		34											48.71	35	35	35				51.43	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	25	25	25	25	25	25	25	25	25				25		25
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		34												29							29						29																	29			29								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	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																														
H7220	010	0	1	01	01	H7220_010_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7220	010	0	1	01	01	H7220_010_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					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																														
H7220	010	0	1	01	01	H7220_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											82.99	25	25	25				82.48	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H7220	010	0	1	01	01	H7220_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											77.54	35	35	35				48.37	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	25	25	25	25	25	25	25	25	25				25		25
H7220	010	0	1	01	01	H7220_010_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																														
H7220	010	0	1	01	01	H7220_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			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	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	001	0	1	01	01	H7239_001_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	25	25	25						25				25		25
H7239	001	0	1	01	01	H7239_001_0	7			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	25	25	25						25				25		25
H7239	001	0	1	01	01	H7239_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	97.00	194.00	281.00																					281.00																97.00				97.00		3.23						3.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	001	0	1	01	01	H7239_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				114.46	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7239	001	0	1	01	01	H7239_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	002	0	1	01	01	H7239_002_0	7		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																														
H7239	002	0	1	01	01	H7239_002_0	7		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	25	25	25						25				25		25
H7239	002	0	1	01	01	H7239_002_0	7		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				79.61	25	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	25	25	25						25				25		25
H7239	002	0	1	01	01	H7239_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				47.81	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	002	0	1	01	01	H7239_002_0	7		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				144.30	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7239	002	0	1	01	01	H7239_002_0	7		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																														
H7239	003	0	1	01	01	H7239_003_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	003	0	1	01	01	H7239_003_0	6			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	25	25	25						25				25		25
H7239	003	0	1	01	01	H7239_003_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				77.46	25	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	25	25	25						25				25		25
H7239	003	0	1	01	01	H7239_003_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				51.30	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	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				110.81	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7239	003	0	1	01	01	H7239_003_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	004	0	1	01	01	H7239_004_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																														
H7239	004	0	1	01	01	H7239_004_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	25	25	25						25				25		25
H7239	004	0	1	01	01	H7239_004_0	5			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				126.10	25	25	25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H7239	004	0	1	01	01	H7239_004_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				55.11	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	004	0	1	01	01	H7239_004_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				185.71	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7239	004	0	1	01	01	H7239_004_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																														
H7239	005	0	1	01	01	H7239_005_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7239	005	0	1	01	01	H7239_005_0	6			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	25	25	25						25				25		25
H7239	005	0	1	01	01	H7239_005_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	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	25	25	25						25				25		25
H7239	005	0	1	01	01	H7239_005_0	6			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	005	0	1	01	01	H7239_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				104.27	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7239	005	0	1	01	01	H7239_005_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7284	001	0	1	04	01	H7284_001_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	0		0				25		25	0		0	0		0
H7284	001	0	1	04	01	H7284_001_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	25		25				25		25	25		0	25		25
H7284	001	0	1	04	01	H7284_001_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	25		25				25		25	25		25	25		25
H7284	001	0	1	04	01	H7284_001_0	3			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	25		25				25		25	25		25	25		25
H7284	001	0	1	04	01	H7284_001_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	25						25			25			25		25
H7284	008	0	1	04	01	H7284_008_0	2			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	0		0				25		25	0		0	0		0
H7284	008	0	1	04	01	H7284_008_0	2			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	25		25				25		25	25		0	25		25
H7284	008	0	1	04	01	H7284_008_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7284	008	0	1	04	01	H7284_008_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7284	008	0	1	04	01	H7284_008_0	2			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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H7284	009	0	1	04	01	H7284_009_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				72.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H7284	010	0	1	04	01	H7284_010_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	0		0				25		25	0		0	0		0
H7284	010	0	1	04	01	H7284_010_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	0		0				25		25	0		0	0		0
H7284	010	0	1	04	01	H7284_010_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7284	010	0	1	04	01	H7284_010_0	4		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	25		25				25		25	25		25	25		25
H7284	010	0	1	04	01	H7284_010_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	25						25			25			25		25
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					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	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											71.70	24	24	24				94.96	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											37.20	25	25	25				42.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											516.71	25						683.64	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	25			25			25			25			25		25
H7301	006	0	1	04	01	H7301_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																														
H7301	006	0	1	04	01	H7301_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																														
H7301	006	0	1	04	01	H7301_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											69.89	24	24	24				99.00	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	006	0	1	04	01	H7301_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											37.79	25	25	25				43.43	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	006	0	1	04	01	H7301_006_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											501.65	25						569.24	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	25			25			25			25			25		25
H7301	007	0	1	04	01	H7301_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																														
H7301	007	0	1	04	01	H7301_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																														
H7301	007	0	1	04	01	H7301_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											66.74	24	24	24				96.20	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	007	0	1	04	01	H7301_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											38.10	25	25	25				43.61	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	007	0	1	04	01	H7301_007_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											533.76	25						640.51	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	25			25			25			25			25		25
H7301	009	0	1	04	01	H7301_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																														
H7301	009	0	1	04	01	H7301_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																														
H7301	009	0	1	04	01	H7301_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											69.65	24	24	24				91.37	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	009	0	1	04	01	H7301_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											35.65	25	25	25				42.40	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	009	0	1	04	01	H7301_009_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											556.49	25						543.08	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	25			25			25			25			25		25
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											75.47	24	24	24				101.16	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											44.98	25	25	25				42.94	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											545.85	25						605.44	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	25			25			25			25			25		25
H7301	021	0	1	04	01	H7301_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																														
H7301	021	0	1	04	01	H7301_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																														
H7301	021	0	1	04	01	H7301_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											64.49	24	24	24				90.60	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	021	0	1	04	01	H7301_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											39.40	25	25	25				44.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	021	0	1	04	01	H7301_021_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											542.55	25						558.12	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	25			25			25			25			25		25
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											67.52	24	24	24				89.90	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											38.55	25	25	25				44.96	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											546.12	25						639.30	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	25			25			25			25			25		25
H7301	032	0	1	04	01	H7301_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																														
H7301	032	0	1	04	01	H7301_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																														
H7301	032	0	1	04	01	H7301_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											63.61	24	24	24				90.01	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	032	0	1	04	01	H7301_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											40.02	25	25	25				46.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	032	0	1	04	01	H7301_032_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											550.78	25						681.93	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	25			25			25			25			25		25
H7301	033	0	1	04	01	H7301_033_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	033	0	1	04	01	H7301_033_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	033	0	1	04	01	H7301_033_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	24	24	24				90.14	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	033	0	1	04	01	H7301_033_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											40.00	25	25	25				47.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	033	0	1	04	01	H7301_033_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											549.40	25						669.55	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	25			25			25			25			25		25
H7301	034	0	1	04	01	H7301_034_0	2			Preferred Generic	4	11	1	2	1	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00					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	034	0	1	04	01	H7301_034_0	2			Generic	4	01	1	2	2	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31								12.00	24.00	36.00					0.00	0.00	0.00											12.00	24.00	36.00				0.00	0.00	0.00					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	034	0	1	04	01	H7301_034_0	2			Preferred Brand	4	11	1	1	3	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											65.16	24	24	24				90.29	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H7301	034	0	1	04	01	H7301_034_0	2			Non-Preferred Drug	4	11	1	1	4	1		111	10		111	1				30	60	100	1	2				30	60	100		10	31											39.98	25	25	25				48.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7301	034	0	1	04	01	H7301_034_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											547.98	25						657.85	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	25			25			25			25			25		25
H7323	007	0	1	04	01	H7323_007_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H7323	007	0	1	04	01	H7323_007_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H7323	007	0	1	04	01	H7323_007_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											128.24	25	25	25				128.24	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7323	007	0	1	04	01	H7323_007_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											78.71	37	37	37				76.59	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7323	007	0	1	04	01	H7323_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7323	007	0	1	04	01	H7323_007_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H7323	012	0	1	04	01	H7323_012_0	7			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H7323	012	0	1	04	01	H7323_012_0	7			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											131.13	25	25	25				131.13	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7323	012	0	1	04	01	H7323_012_0	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.48	35	35	35				74.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7323	012	0	1	04	01	H7323_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7323	012	0	1	04	01	H7323_012_0	7			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	9			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H7326	001	0	1	04	01	H7326_001_0	9			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H7326	001	0	1	04	01	H7326_001_0	9			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											125.63	25	25	25				125.63	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7326	001	0	1	04	01	H7326_001_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											63.69	36	36	36				61.92	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7326	001	0	1	04	01	H7326_001_0	9			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7326	001	0	1	04	01	H7326_001_0	9			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7326	007	0	1	04	01	H7326_007_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											90.24	21	21	21				90.24	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H7326	007	0	1	04	01	H7326_007_0	8			Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7326	007	0	1	04	01	H7326_007_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7355	001	0	1	04	01	H7355_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	0	0	0				0	0	0				0		0
H7355	001	0	1	04	01	H7355_001_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	0	0	0				0	0	0				0		0
H7355	001	0	1	04	01	H7355_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				33.00	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	19	19	19				19	19	19				19		19
H7355	001	0	1	04	01	H7355_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				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	25	25	25				25	25	25				25		25
H7355	001	0	1	04	01	H7355_001_0	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	25						25						25		25
H7355	002	0	1	04	01	H7355_002_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	0	0	0				0	0	0				0		0
H7355	002	0	1	04	01	H7355_002_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	25	25	25				25	25	25				25		25
H7355	002	0	1	04	01	H7355_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				39.00	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	21	21	21				21	21	21				21		21
H7355	002	0	1	04	01	H7355_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				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	25	25	25				25	25	25				25		25
H7355	002	0	1	04	01	H7355_002_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	25						25						25		25
H7355	003	0	1	04	01	H7355_003_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7355	003	0	1	04	01	H7355_003_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	003	0	1	04	01	H7355_003_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	003	0	1	04	01	H7355_003_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	003	0	1	04	01	H7355_003_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7355	003	0	1	04	01	H7355_003_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7355	004	0	1	04	01	H7355_004_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7355	004	0	1	04	01	H7355_004_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	004	0	1	04	01	H7355_004_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	004	0	1	04	01	H7355_004_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				63.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	004	0	1	04	01	H7355_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7355	004	0	1	04	01	H7355_004_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7355	006	0	1	04	01	H7355_006_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7355	006	0	1	04	01	H7355_006_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7355	006	0	1	04	01	H7355_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				32.00	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	20	20	20				20	20	20				20		20
H7355	006	0	1	04	01	H7355_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				95.00	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		35.00	25	25	25				25	25	25				25		25
H7355	006	0	1	04	01	H7355_006_0	6			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	25						25						25		25
H7355	007	0	1	04	01	H7355_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7355	007	0	1	04	01	H7355_007_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7355	007	0	1	04	01	H7355_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H7355	007	0	1	04	01	H7355_007_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7355	007	0	1	04	01	H7355_007_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7355	007	0	1	04	01	H7355_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7355	009	0	1	04	01	H7355_009_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7355	009	0	1	04	01	H7355_009_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	009	0	1	04	01	H7355_009_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	009	0	1	04	01	H7355_009_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	009	0	1	04	01	H7355_009_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7355	009	0	1	04	01	H7355_009_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7355	010	0	1	04	01	H7355_010_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7355	010	0	1	04	01	H7355_010_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7355	010	0	1	04	01	H7355_010_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7355	010	0	1	04	01	H7355_010_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7355	010	0	1	04	01	H7355_010_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7355	010	0	1	04	01	H7355_010_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7379	001	0	1	04	01	H7379_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	25	25	25				25	25	25				25		25
H7379	001	0	1	04	01	H7379_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H7379	001	0	1	04	01	H7379_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				26.93	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	35.00	35.00				35.00		35.00	20	20	20				20	20	20				20		20
H7379	001	0	1	04	01	H7379_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				65.40	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		35.00	25	25	25				25	25	25				25		25
H7379	001	0	1	04	01	H7379_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				710.18	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7379	002	0	1	04	01	H7379_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	25	25	25				25	25	25				25		25
H7379	002	0	1	04	01	H7379_002_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H7379	002	0	1	04	01	H7379_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	47.00	94.00	141.00																			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	25	25	25				25	25	25				25		25
H7379	002	0	1	04	01	H7379_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				75.31	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	25	25	25				25	25	25				25		25
H7379	002	0	1	04	01	H7379_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				723.24	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7397	001	0	1	04	01	H7397_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	0	0	0				0	0	0				0		0
H7397	001	0	1	04	01	H7397_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7397	001	0	1	04	01	H7397_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				33.00	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	19	19	19				19	19	19				19		19
H7397	001	0	1	04	01	H7397_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	001	0	1	04	01	H7397_001_0	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	25						25						25		25
H7397	002	0	1	04	01	H7397_002_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	0	0	0				0	0	0				0		0
H7397	002	0	1	04	01	H7397_002_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	25	25	25				25	25	25				25		25
H7397	002	0	1	04	01	H7397_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				39.00	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	21	21	21				21	21	21				21		21
H7397	002	0	1	04	01	H7397_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				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	25	25	25				25	25	25				25		25
H7397	002	0	1	04	01	H7397_002_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	25						25						25		25
H7397	003	0	1	04	01	H7397_003_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7397	003	0	1	04	01	H7397_003_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	003	0	1	04	01	H7397_003_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				41.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	003	0	1	04	01	H7397_003_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	003	0	1	04	01	H7397_003_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7397	003	0	1	04	01	H7397_003_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7397	004	0	1	04	01	H7397_004_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7397	004	0	1	04	01	H7397_004_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	004	0	1	04	01	H7397_004_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				41.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	004	0	1	04	01	H7397_004_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	004	0	1	04	01	H7397_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7397	004	0	1	04	01	H7397_004_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7397	006	0	1	04	01	H7397_006_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7397	006	0	1	04	01	H7397_006_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7397	006	0	1	04	01	H7397_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				32.00	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	20	20	20				20	20	20				20		20
H7397	006	0	1	04	01	H7397_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				95.00	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		35.00	25	25	25				25	25	25				25		25
H7397	006	0	1	04	01	H7397_006_0	6			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	25						25						25		25
H7397	007	0	1	04	01	H7397_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7397	007	0	1	04	01	H7397_007_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7397	007	0	1	04	01	H7397_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H7397	007	0	1	04	01	H7397_007_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7397	007	0	1	04	01	H7397_007_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7397	007	0	1	04	01	H7397_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7397	009	0	1	04	01	H7397_009_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7397	009	0	1	04	01	H7397_009_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	009	0	1	04	01	H7397_009_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				40.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	009	0	1	04	01	H7397_009_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				58.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	009	0	1	04	01	H7397_009_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7397	009	0	1	04	01	H7397_009_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7397	010	0	1	04	01	H7397_010_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7397	010	0	1	04	01	H7397_010_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7397	010	0	1	04	01	H7397_010_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7397	010	0	1	04	01	H7397_010_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7397	010	0	1	04	01	H7397_010_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7397	010	0	1	04	01	H7397_010_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7435	001	0	1	01	01	H7435_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7435	001	0	1	01	01	H7435_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7435	001	0	1	01	01	H7435_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											82.94	20	20	20				82.94	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H7435	001	0	1	01	01	H7435_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7435	001	0	1	01	01	H7435_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7435	001	0	1	01	01	H7435_001_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7464	008	1	1	01	01	H7464_008_1	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H7464	008	1	1	01	01	H7464_008_1	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7464	008	1	1	01	01	H7464_008_1	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H7464	008	1	1	01	01	H7464_008_1	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7464	008	1	1	01	01	H7464_008_1	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7464	008	2	1	01	01	H7464_008_2	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H7464	008	2	1	01	01	H7464_008_2	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7464	008	2	1	01	01	H7464_008_2	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				56.00	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	25		25						25				25		25
H7464	008	2	1	01	01	H7464_008_2	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				50.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7464	008	2	1	01	01	H7464_008_2	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				375.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7464	012	0	1	02	01	H7464_012_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
H7464	012	0	1	02	01	H7464_012_0	4		N	Generic	4	01	1	2	2	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7464	012	0	1	02	01	H7464_012_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				57.00	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	25		25						25				25		25
H7464	012	0	1	02	01	H7464_012_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7464	012	0	1	02	01	H7464_012_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				383.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7471	001	0	1	04	01	H7471_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	0	0	0				0	0	0				0		0
H7471	001	0	1	04	01	H7471_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	001	0	1	04	01	H7471_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				21.00	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	19	19	19				19	19	19				19		19
H7471	001	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	001	0	1	04	01	H7471_001_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7471	002	0	1	04	01	H7471_002_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	0	0	0				0	0	0				0		0
H7471	002	0	1	04	01	H7471_002_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	25	25	25				25	25	25				25		25
H7471	002	0	1	04	01	H7471_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				39.00	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	21	21	21				21	21	21				21		21
H7471	002	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	002	0	1	04	01	H7471_002_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	25						25						25		25
H7471	004	0	1	04	01	H7471_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	004	0	1	04	01	H7471_004_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	25	25	25				25	25	25				25		25
H7471	004	0	1	04	01	H7471_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				39.00	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	22	22	22				22	22	22				22		22
H7471	004	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	004	0	1	04	01	H7471_004_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	25						25						25		25
H7471	005	0	1	04	01	H7471_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7471	005	0	1	04	01	H7471_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	005	0	1	04	01	H7471_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				21.00	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	19	19	19				19	19	19				19		19
H7471	005	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	005	0	1	04	01	H7471_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7471	006	0	1	04	01	H7471_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	0	0	0				0	0	0				0		0
H7471	006	0	1	04	01	H7471_006_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	25	25	25				25	25	25				25		25
H7471	006	0	1	04	01	H7471_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				39.00	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	21	21	21				21	21	21				21		21
H7471	006	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	006	0	1	04	01	H7471_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	25						25						25		25
H7471	007	0	1	04	01	H7471_007_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	0	0	0				0	0	0				0		0
H7471	007	0	1	04	01	H7471_007_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	25	25	25				25	25	25				25		25
H7471	007	0	1	04	01	H7471_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				39.00	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	22	22	22				22	22	22				22		22
H7471	007	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	007	0	1	04	01	H7471_007_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	25						25						25		25
H7471	008	0	1	04	01	H7471_008_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	0	0	0				0	0	0				0		0
H7471	008	0	1	04	01	H7471_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	008	0	1	04	01	H7471_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				21.00	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	20	20	20				20	20	20				20		20
H7471	008	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	008	0	1	04	01	H7471_008_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7471	009	0	1	04	01	H7471_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	009	0	1	04	01	H7471_009_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	25	25	25				25	25	25				25		25
H7471	009	0	1	04	01	H7471_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				39.00	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	21	21	21				21	21	21				21		21
H7471	009	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	009	0	1	04	01	H7471_009_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	25						25						25		25
H7471	011	0	1	04	01	H7471_011_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	0	0	0				0	0	0				0		0
H7471	011	0	1	04	01	H7471_011_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	011	0	1	04	01	H7471_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				21.00	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	20	20	20				20	20	20				20		20
H7471	011	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	011	0	1	04	01	H7471_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7471	012	0	1	04	01	H7471_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7471	012	0	1	04	01	H7471_012_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	25	25	25				25	25	25				25		25
H7471	012	0	1	04	01	H7471_012_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	21	21	21				21	21	21				21		21
H7471	012	0	1	04	01	H7471_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				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	25	25	25				25	25	25				25		25
H7471	012	0	1	04	01	H7471_012_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	25						25						25		25
H7471	013	0	1	04	01	H7471_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7471	013	0	1	04	01	H7471_013_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7471	013	0	1	04	01	H7471_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7471	013	0	1	04	01	H7471_013_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7471	013	0	1	04	01	H7471_013_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7471	013	0	1	04	01	H7471_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7471	014	0	1	04	01	H7471_014_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7471	014	0	1	04	01	H7471_014_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7471	014	0	1	04	01	H7471_014_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7471	014	0	1	04	01	H7471_014_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7471	014	0	1	04	01	H7471_014_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7471	014	0	1	04	01	H7471_014_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7471	015	0	1	04	01	H7471_015_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7471	015	0	1	04	01	H7471_015_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7471	015	0	1	04	01	H7471_015_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7471	015	0	1	04	01	H7471_015_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7471	015	0	1	04	01	H7471_015_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7471	015	0	1	04	01	H7471_015_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7471	016	0	1	04	01	H7471_016_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7471	016	0	1	04	01	H7471_016_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7471	016	0	1	04	01	H7471_016_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7471	016	0	1	04	01	H7471_016_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7471	016	0	1	04	01	H7471_016_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7471	016	0	1	04	01	H7471_016_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7471	017	0	1	04	01	H7471_017_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7471	017	0	1	04	01	H7471_017_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7471	017	0	1	04	01	H7471_017_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7471	017	0	1	04	01	H7471_017_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7471	017	0	1	04	01	H7471_017_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7471	017	0	1	04	01	H7471_017_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7511	002	0	1	01	01	H7511_002_0	6			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7511	002	0	1	01	01	H7511_002_0	6			Generic	4	01	1	2	2	1	111		10			1	30	60	90				2	2								10	31	9.00	18.00	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										9.00		9.00	25	25	25										25		25
H7511	002	0	1	01	01	H7511_002_0	6			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	25	25	25										25		25
H7511	002	0	1	01	01	H7511_002_0	6			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	25	25	25										25		25
H7511	002	0	1	01	01	H7511_002_0	6			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				492.68	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	6			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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H7518	001	0	1	04	01	H7518_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H7518	001	0	1	04	01	H7518_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											125.62	25	25	25				125.62	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7518	001	0	1	04	01	H7518_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											70.80	36	36	36				68.84	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7518	001	0	1	04	01	H7518_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7518	001	0	1	04	01	H7518_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7518	003	0	1	04	01	H7518_003_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											84.86	20	20	20				84.86	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H7518	003	0	1	04	01	H7518_003_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H7518	003	0	1	04	01	H7518_003_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H7524	001	0	1	01	01	H7524_001_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7524	001	0	1	01	01	H7524_001_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	001	0	1	01	01	H7524_001_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				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	25	25	25				25	25	25				25		25
H7524	001	0	1	01	01	H7524_001_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	002	0	1	01	01	H7524_002_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H7524	002	0	1	01	01	H7524_002_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7524	002	0	1	01	01	H7524_002_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	002	0	1	01	01	H7524_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				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	25	25	25				25	25	25				25		25
H7524	002	0	1	01	01	H7524_002_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	003	0	1	01	01	H7524_003_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H7524	003	0	1	01	01	H7524_003_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7524	003	0	1	01	01	H7524_003_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	003	0	1	01	01	H7524_003_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				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	25	25	25				25	25	25				25		25
H7524	003	0	1	01	01	H7524_003_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	004	0	1	01	01	H7524_004_0	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H7524	004	0	1	01	01	H7524_004_0	7		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7524	004	0	1	01	01	H7524_004_0	7		N	Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	47.00	94.00	141.00																			47.00	94.00	141.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7524	004	0	1	01	01	H7524_004_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				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	25	25	25				25	25	25				25		25
H7524	004	0	1	01	01	H7524_004_0	7		N	Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7598	004	0	1	01	01	H7598_004_0	7			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	25	25	25						25				25		25
H7598	004	0	1	01	01	H7598_004_0	7			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																					45.00																15.00				15.00		0.50						0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00						45.00				15.00		15.00	25	25	25						25				25		25
H7598	004	0	1	01	01	H7598_004_0	7			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	90				1	2			90				30		31				44.65	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	19	19	19						19				19		19
H7598	004	0	1	01	01	H7598_004_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	90				1	2			90				30		31				51.96	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H7598	004	0	1	01	01	H7598_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				710.21	29																																					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7605	001	0	1	01	01	H7605_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	0	0	0				0	0	0				0		0
H7605	001	0	1	01	01	H7605_001_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																			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	25	25	25				25	25	25				25		25
H7605	001	0	1	01	01	H7605_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				62.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7605	001	0	1	01	01	H7605_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				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	25	25	25				25	25	25				25		25
H7605	001	0	1	01	01	H7605_001_0	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	25						25						25		25
H7605	002	0	1	01	01	H7605_002_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	0	0	0				0	0	0				0		0
H7605	002	0	1	01	01	H7605_002_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	25	25	25				25	25	25				25		25
H7605	002	0	1	01	01	H7605_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				61.00	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	22	22	22				22	22	22				22		22
H7605	002	0	1	01	01	H7605_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				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	25	25	25				25	25	25				25		25
H7605	002	0	1	01	01	H7605_002_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	25						25						25		25
H7605	004	0	1	01	01	H7605_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7605	004	0	1	01	01	H7605_004_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	0	0	0				0	0	0				0		0
H7605	004	0	1	01	01	H7605_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				60.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7605	004	0	1	01	01	H7605_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7605	004	0	1	01	01	H7605_004_0	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	25						25						25		25
H7605	005	0	1	01	01	H7605_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7605	005	0	1	01	01	H7605_005_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	25	25	25				25	25	25				25		25
H7605	005	0	1	01	01	H7605_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				61.00	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	22	22	22				22	22	22				22		22
H7605	005	0	1	01	01	H7605_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				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	25	25	25				25	25	25				25		25
H7605	005	0	1	01	01	H7605_005_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	25						25						25		25
H7605	007	0	1	01	01	H7605_007_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	0	0	0				0	0	0				0		0
H7605	007	0	1	01	01	H7605_007_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																			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	25	25	25				25	25	25				25		25
H7605	007	0	1	01	01	H7605_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				57.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7605	007	0	1	01	01	H7605_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				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	25	25	25				25	25	25				25		25
H7605	007	0	1	01	01	H7605_007_0	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	25						25						25		25
H7605	008	0	1	01	01	H7605_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	0	0	0				0	0	0				0		0
H7605	008	0	1	01	01	H7605_008_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	25	25	25				25	25	25				25		25
H7605	008	0	1	01	01	H7605_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				66.00	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	22	22	22				22	22	22				22		22
H7605	008	0	1	01	01	H7605_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				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7605	008	0	1	01	01	H7605_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	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	25	25	25				25	25	25				25		25
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				57.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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	25	25	25				25	25	25				25		25
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	28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7605	010	0	1	01	01	H7605_010_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	0	0	0				0	0	0				0		0
H7605	010	0	1	01	01	H7605_010_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																			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	25	25	25				25	25	25				25		25
H7605	010	0	1	01	01	H7605_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				60.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7605	010	0	1	01	01	H7605_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				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	25	25	25				25	25	25				25		25
H7605	010	0	1	01	01	H7605_010_0	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	25						25						25		25
H7605	016	0	1	01	01	H7605_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																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7605	016	0	1	01	01	H7605_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7605	016	0	1	01	01	H7605_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				76.00	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	24	24	24				24	24	24				24		24
H7605	016	0	1	01	01	H7605_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				90.00	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		35.00	25	25	25				25	25	25				25		25
H7605	016	0	1	01	01	H7605_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7605	016	0	1	01	01	H7605_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	014	0	1	01	01	H7607_014_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																														
H7607	014	0	1	01	01	H7607_014_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																														
H7607	014	0	1	01	01	H7607_014_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	40.00	80.00	120.00																			40.00	80.00	80.00																40.00				40.00		1.33			1.33			1.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H7607	014	0	1	01	01	H7607_014_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	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 Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H7607	014	0	1	01	01	H7607_014_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				639.99	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7607	014	0	1	01	01	H7607_014_0	12			Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	015	0	1	01	01	H7607_015_0	12			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	015	0	1	01	01	H7607_015_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																														
H7607	015	0	1	01	01	H7607_015_0	12			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	30.00	60.00	90.00																			30.00	60.00	60.00																30.00				30.00		1.00			1.00			0.97	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00				30.00	60.00	60.00				30.00		30.00	25	25	25				25	25	25				25		25
H7607	015	0	1	01	01	H7607_015_0	12			Non-Preferred Drug	4	11	1	2	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H7607	015	0	1	01	01	H7607_015_0	12			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				461.40	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7607	015	0	1	01	01	H7607_015_0	12			Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	016	0	1	01	01	H7607_016_0	11			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	016	0	1	01	01	H7607_016_0	11			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.05	10	10	10																		10	10	10															10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	016	0	1	01	01	H7607_016_0	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				134.45	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	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H7607	016	0	1	01	01	H7607_016_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				82.74	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	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H7607	016	0	1	01	01	H7607_016_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				643.10	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	25						25						25		25
H7607	016	0	1	01	01	H7607_016_0	11			Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	017	0	1	01	01	H7607_017_0	11			Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.03	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	017	0	1	01	01	H7607_017_0	11			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				13.35	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7607	017	0	1	01	01	H7607_017_0	11			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				133.34	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H7607	017	0	1	01	01	H7607_017_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				82.26	25	25	25																		25	25	25															25			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	25	25	25				25	25	25				25		25
H7607	017	0	1	01	01	H7607_017_0	11			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				642.43	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	25						25						25		25
H7607	017	0	1	01	01	H7607_017_0	11			Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7617	003	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	003	0	1	04	01	H7617_003_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	0		0				25		25	0		0	0		0
H7617	003	0	1	04	01	H7617_003_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	25		25				25		25	25		25	25		25
H7617	003	0	1	04	01	H7617_003_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H7617	003	0	1	04	01	H7617_003_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	25						25			25			25		25
H7617	004	0	1	04	01	H7617_004_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	0		0				25		25	0		0	0		0
H7617	004	0	1	04	01	H7617_004_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	004	0	1	04	01	H7617_004_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	25		25				25		25	25		25	25		25
H7617	004	0	1	04	01	H7617_004_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	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	25		25				25		25	25		25	25		25
H7617	004	0	1	04	01	H7617_004_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	25						25			25			25		25
H7617	005	0	1	04	01	H7617_005_0	2			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	0		0				25		25	0		0	0		0
H7617	005	0	1	04	01	H7617_005_0	2			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	25		25				25		25	25		0	25		25
H7617	005	0	1	04	01	H7617_005_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	005	0	1	04	01	H7617_005_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				66.00	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	25		25				25		25	25		25	25		25
H7617	005	0	1	04	01	H7617_005_0	2			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	25						25			25			25		25
H7617	006	0	1	04	01	H7617_006_0	4		N	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	0		0				25		25	0		0	0		0
H7617	006	0	1	04	01	H7617_006_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	0		0				25		25	0		0	0		0
H7617	006	0	1	04	01	H7617_006_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	006	0	1	04	01	H7617_006_0	4		N	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	25		25				25		25	25		25	25		25
H7617	006	0	1	04	01	H7617_006_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	25						25			25			25		25
H7617	007	0	1	04	01	H7617_007_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	0		0				25		25	0		0	0		0
H7617	007	0	1	04	01	H7617_007_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	25		25				25		25	25		0	25		25
H7617	007	0	1	04	01	H7617_007_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	25		25				25		25	25		25	25		25
H7617	007	0	1	04	01	H7617_007_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	007	0	1	04	01	H7617_007_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	25						25			25			25		25
H7617	008	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	008	0	1	04	01	H7617_008_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	25		25				25		25	25		0	25		25
H7617	008	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	008	0	1	04	01	H7617_008_0	3			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	25		25				25		25	25		25	25		25
H7617	008	0	1	04	01	H7617_008_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	25						25			25			25		25
H7617	009	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	009	0	1	04	01	H7617_009_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	25		25				25		25	25		0	25		25
H7617	009	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	009	0	1	04	01	H7617_009_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	25		25				25		25	25		25	25		25
H7617	009	0	1	04	01	H7617_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	25						25			25			25		25
H7617	010	0	1	04	01	H7617_010_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	0		0				25		25	0		0	0		0
H7617	010	0	1	04	01	H7617_010_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	25		25				25		25	25		0	25		25
H7617	010	0	1	04	01	H7617_010_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	25		25				25		25	25		25	25		25
H7617	010	0	1	04	01	H7617_010_0	3			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	25		25				25		25	25		25	25		25
H7617	010	0	1	04	01	H7617_010_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	25						25			25			25		25
H7617	011	0	1	04	01	H7617_011_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	0		0				25		25	0		0	0		0
H7617	011	0	1	04	01	H7617_011_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	25		25				25		25	25		0	25		25
H7617	011	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	011	0	1	04	01	H7617_011_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	011	0	1	04	01	H7617_011_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	25						25			25			25		25
H7617	013	0	1	04	01	H7617_013_0	2			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	0		0				25		25	0		0	0		0
H7617	013	0	1	04	01	H7617_013_0	2			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	25		25				25		25	25		0	25		25
H7617	013	0	1	04	01	H7617_013_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	013	0	1	04	01	H7617_013_0	2			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	25		25				25		25	25		25	25		25
H7617	013	0	1	04	01	H7617_013_0	2			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	25						25			25			25		25
H7617	014	0	1	04	01	H7617_014_0	2			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	0		0				25		25	0		0	0		0
H7617	014	0	1	04	01	H7617_014_0	2			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	25		25				25		25	25		0	25		25
H7617	014	0	1	04	01	H7617_014_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	014	0	1	04	01	H7617_014_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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	25		25				25		25	25		25	25		25
H7617	014	0	1	04	01	H7617_014_0	2			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	25						25			25			25		25
H7617	015	0	1	04	01	H7617_015_0	2			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	0		0				25		25	0		0	0		0
H7617	015	0	1	04	01	H7617_015_0	2			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	25		25				25		25	25		0	25		25
H7617	015	0	1	04	01	H7617_015_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	015	0	1	04	01	H7617_015_0	2			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	25		25				25		25	25		25	25		25
H7617	015	0	1	04	01	H7617_015_0	2			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	25						25			25			25		25
H7617	016	0	1	04	01	H7617_016_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	0		0				25		25	0		0	0		0
H7617	016	0	1	04	01	H7617_016_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	016	0	1	04	01	H7617_016_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	25		25				25		25	25		25	25		25
H7617	016	0	1	04	01	H7617_016_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	016	0	1	04	01	H7617_016_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	25						25			25			25		25
H7617	017	0	1	04	01	H7617_017_0	2			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	0		0				25		25	0		0	0		0
H7617	017	0	1	04	01	H7617_017_0	2			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	25		25				25		25	25		0	25		25
H7617	017	0	1	04	01	H7617_017_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	017	0	1	04	01	H7617_017_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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	25		25				25		25	25		25	25		25
H7617	017	0	1	04	01	H7617_017_0	2			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	25						25			25			25		25
H7617	018	0	1	04	01	H7617_018_0	2			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	0		0				25		25	0		0	0		0
H7617	018	0	1	04	01	H7617_018_0	2			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	25		25				25		25	25		0	25		25
H7617	018	0	1	04	01	H7617_018_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	018	0	1	04	01	H7617_018_0	2			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	25		25				25		25	25		25	25		25
H7617	018	0	1	04	01	H7617_018_0	2			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	25						25			25			25		25
H7617	019	0	1	04	01	H7617_019_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	0		0				25		25	0		0	0		0
H7617	019	0	1	04	01	H7617_019_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	25		25				25		25	25		0	25		25
H7617	019	0	1	04	01	H7617_019_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	25		25				25		25	25		25	25		25
H7617	019	0	1	04	01	H7617_019_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
H7617	019	0	1	04	01	H7617_019_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	25						25			25			25		25
H7617	020	0	1	04	01	H7617_020_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	0		0				25		25	0		0	0		0
H7617	020	0	1	04	01	H7617_020_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	25		25				25		25	25		0	25		25
H7617	020	0	1	04	01	H7617_020_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	25		25				25		25	25		25	25		25
H7617	020	0	1	04	01	H7617_020_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	020	0	1	04	01	H7617_020_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	25						25			25			25		25
H7617	023	0	1	04	01	H7617_023_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	0		0				25		25	0		0	0		0
H7617	023	0	1	04	01	H7617_023_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	25		25				25		25	25		0	25		25
H7617	023	0	1	04	01	H7617_023_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	25		25				25		25	25		25	25		25
H7617	023	0	1	04	01	H7617_023_0	3			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	25		25				25		25	25		25	25		25
H7617	023	0	1	04	01	H7617_023_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	25						25			25			25		25
H7617	024	0	1	04	01	H7617_024_0	2			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	0		0				25		25	0		0	0		0
H7617	024	0	1	04	01	H7617_024_0	2			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	25		25				25		25	25		0	25		25
H7617	024	0	1	04	01	H7617_024_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	024	0	1	04	01	H7617_024_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	024	0	1	04	01	H7617_024_0	2			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	25						25			25			25		25
H7617	025	0	1	04	01	H7617_025_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	0		0				25		25	0		0	0		0
H7617	025	0	1	04	01	H7617_025_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	025	0	1	04	01	H7617_025_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	25		25				25		25	25		25	25		25
H7617	025	0	1	04	01	H7617_025_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	025	0	1	04	01	H7617_025_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	25						25			25			25		25
H7617	026	0	1	04	01	H7617_026_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	0		0				25		25	0		0	0		0
H7617	026	0	1	04	01	H7617_026_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	026	0	1	04	01	H7617_026_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	25		25				25		25	25		25	25		25
H7617	026	0	1	04	01	H7617_026_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	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	25		25				25		25	25		25	25		25
H7617	026	0	1	04	01	H7617_026_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	25						25			25			25		25
H7617	027	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	027	0	1	04	01	H7617_027_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	027	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	027	0	1	04	01	H7617_027_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	027	0	1	04	01	H7617_027_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	25						25			25			25		25
H7617	028	0	1	04	01	H7617_028_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	0		0				25		25	0		0	0		0
H7617	028	0	1	04	01	H7617_028_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	028	0	1	04	01	H7617_028_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	25		25				25		25	25		25	25		25
H7617	028	0	1	04	01	H7617_028_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	25		25				25		25	25		25	25		25
H7617	028	0	1	04	01	H7617_028_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	25						25			25			25		25
H7617	029	0	1	04	01	H7617_029_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	0		0				25		25	0		0	0		0
H7617	029	0	1	04	01	H7617_029_0	3			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	25		25				25		25	25		0	25		25
H7617	029	0	1	04	01	H7617_029_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	25		25				25		25	25		25	25		25
H7617	029	0	1	04	01	H7617_029_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				90.00	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	25		25				25		25	25		25	25		25
H7617	029	0	1	04	01	H7617_029_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	25						25			25			25		25
H7617	030	0	1	04	01	H7617_030_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	0		0				25		25	0		0	0		0
H7617	030	0	1	04	01	H7617_030_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	030	0	1	04	01	H7617_030_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	25		25				25		25	25		25	25		25
H7617	030	0	1	04	01	H7617_030_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	030	0	1	04	01	H7617_030_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	25						25			25			25		25
H7617	031	0	1	04	01	H7617_031_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	0		0				25		25	0		0	0		0
H7617	031	0	1	04	01	H7617_031_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	031	0	1	04	01	H7617_031_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	25		25				25		25	25		25	25		25
H7617	031	0	1	04	01	H7617_031_0	3			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	25		25				25		25	25		25	25		25
H7617	031	0	1	04	01	H7617_031_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	25						25			25			25		25
H7617	032	0	1	04	01	H7617_032_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	0		0				25		25	0		0	0		0
H7617	032	0	1	04	01	H7617_032_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	032	0	1	04	01	H7617_032_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	25		25				25		25	25		25	25		25
H7617	032	0	1	04	01	H7617_032_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	032	0	1	04	01	H7617_032_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	25						25			25			25		25
H7617	033	0	1	04	01	H7617_033_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	0		0				25		25	0		0	0		0
H7617	033	0	1	04	01	H7617_033_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, Select Care Drugs	0.00		0.00				20.00		60.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H7617	033	0	1	04	01	H7617_033_0	4			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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	033	0	1	04	01	H7617_033_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				47.00	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	25		25				25		25	25		25	25		25
H7617	033	0	1	04	01	H7617_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, Select Care Drugs	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H7617	033	0	1	04	01	H7617_033_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	0		0				0		0	0		0	0		0
H7617	034	0	1	04	01	H7617_034_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	0		0				25		25	0		0	0		0
H7617	034	0	1	04	01	H7617_034_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	25		25				25		25	25		0	25		25
H7617	034	0	1	04	01	H7617_034_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	034	0	1	04	01	H7617_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				71.00	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	25		25				25		25	25		25	25		25
H7617	034	0	1	04	01	H7617_034_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	25						25			25			25		25
H7617	034	0	1	04	01	H7617_034_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	0		0				0		0	0		0	0		0
H7617	035	0	1	04	01	H7617_035_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	0		0				25		25	0		0	0		0
H7617	035	0	1	04	01	H7617_035_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	035	0	1	04	01	H7617_035_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	25		25				25		25	25		25	25		25
H7617	035	0	1	04	01	H7617_035_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				69.00	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	25		25				25		25	25		25	25		25
H7617	035	0	1	04	01	H7617_035_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	25						25			25			25		25
H7617	036	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	036	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	036	0	1	04	01	H7617_036_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	036	0	1	04	01	H7617_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				51.00	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	25		25				25		25	25		25	25		25
H7617	036	0	1	04	01	H7617_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	25						25			25			25		25
H7617	037	0	1	04	01	H7617_037_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	0		0				25		25	0		0	0		0
H7617	037	0	1	04	01	H7617_037_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	0		0				25		25	0		0	0		0
H7617	037	0	1	04	01	H7617_037_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	037	0	1	04	01	H7617_037_0	4		N	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	25		25				25		25	25		25	25		25
H7617	037	0	1	04	01	H7617_037_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	25						25			25			25		25
H7617	038	0	1	04	01	H7617_038_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	0		0				25		25	0		0	0		0
H7617	038	0	1	04	01	H7617_038_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	0		0				25		25	0		0	0		0
H7617	038	0	1	04	01	H7617_038_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	038	0	1	04	01	H7617_038_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H7617	038	0	1	04	01	H7617_038_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	25						25			25			25		25
H7617	039	0	1	04	01	H7617_039_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	0		0				25		25	0		0	0		0
H7617	039	0	1	04	01	H7617_039_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	0		0				25		25	0		0	0		0
H7617	039	0	1	04	01	H7617_039_0	4		N	Preferred Brand	4	11	1	1	3	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	25		25				25		25	25		25	25		25
H7617	039	0	1	04	01	H7617_039_0	4		N	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	25		25				25		25	25		25	25		25
H7617	039	0	1	04	01	H7617_039_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	25						25			25			25		25
H7617	040	0	1	04	01	H7617_040_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	0		0				25		25	0		0	0		0
H7617	040	0	1	04	01	H7617_040_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	040	0	1	04	01	H7617_040_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	040	0	1	04	01	H7617_040_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	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	25		25				25		25	25		25	25		25
H7617	040	0	1	04	01	H7617_040_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	25						25			25			25		25
H7617	041	0	1	04	01	H7617_041_0	2			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	0		0				25		25	0		0	0		0
H7617	041	0	1	04	01	H7617_041_0	2			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	0		0				25		25	0		0	0		0
H7617	041	0	1	04	01	H7617_041_0	2			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	25		25				25		25	25		25	25		25
H7617	041	0	1	04	01	H7617_041_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				47.00	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	25		25				25		25	25		25	25		25
H7617	041	0	1	04	01	H7617_041_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	25						25			25			25		25
H7617	042	0	1	04	01	H7617_042_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	0		0				25		25	0		0	0		0
H7617	042	0	1	04	01	H7617_042_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	042	0	1	04	01	H7617_042_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	25		25				25		25	25		25	25		25
H7617	042	0	1	04	01	H7617_042_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
H7617	042	0	1	04	01	H7617_042_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	25						25			25			25		25
H7617	043	0	1	04	01	H7617_043_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	0		0				25		25	0		0	0		0
H7617	043	0	1	04	01	H7617_043_0	3			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	25		25				25		25	25		0	25		25
H7617	043	0	1	04	01	H7617_043_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	043	0	1	04	01	H7617_043_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				77.00	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	25		25				25		25	25		25	25		25
H7617	043	0	1	04	01	H7617_043_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	25						25			25			25		25
H7617	044	0	1	04	01	H7617_044_0	2			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	0		0				0		0	0		0	0		0
H7617	044	0	1	04	01	H7617_044_0	2			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	25		25				25		25	25		0	25		25
H7617	044	0	1	04	01	H7617_044_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	044	0	1	04	01	H7617_044_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				72.00	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	25		25				25		25	25		25	25		25
H7617	044	0	1	04	01	H7617_044_0	2			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	25						25			25			25		25
H7617	045	0	1	04	01	H7617_045_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	0		0				25		25	0		0	0		0
H7617	045	0	1	04	01	H7617_045_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	045	0	1	04	01	H7617_045_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	25		25				25		25	25		25	25		25
H7617	045	0	1	04	01	H7617_045_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	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	25		25				25		25	25		25	25		25
H7617	045	0	1	04	01	H7617_045_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	25						25			25			25		25
H7617	046	0	1	04	01	H7617_046_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	0		0				25		25	0		0	0		0
H7617	046	0	1	04	01	H7617_046_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	046	0	1	04	01	H7617_046_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	25		25				25		25	25		25	25		25
H7617	046	0	1	04	01	H7617_046_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H7617	046	0	1	04	01	H7617_046_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	25						25			25			25		25
H7617	048	0	1	04	01	H7617_048_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	0		0				25		25	0		0	0		0
H7617	048	0	1	04	01	H7617_048_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	0		0				25		25	0		0	0		0
H7617	048	0	1	04	01	H7617_048_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	048	0	1	04	01	H7617_048_0	4		N	Non-Preferred Drug	4	11	1	1	4	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	25		25				25		25	25		25	25		25
H7617	048	0	1	04	01	H7617_048_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	25						25			25			25		25
H7617	049	0	1	04	01	H7617_049_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	0		0				25		25	0		0	0		0
H7617	049	0	1	04	01	H7617_049_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	2.00		6.00																									20.00		60.00				2.00		0.00				2.00				2.00		0.07				0.67	0.07	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				20.00		60.00	2.00		0.00	2.00		2.00	25		25				25		25	25		0	25		25
H7617	049	0	1	04	01	H7617_049_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	25		25				25		25	25		25	25		25
H7617	049	0	1	04	01	H7617_049_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				56.00	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	25		25				25		25	25		25	25		25
H7617	049	0	1	04	01	H7617_049_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	25						25			25			25		25
H7617	050	0	1	04	01	H7617_050_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	0		0				25		25	0		0	0		0
H7617	050	0	1	04	01	H7617_050_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	050	0	1	04	01	H7617_050_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	25		25				25		25	25		25	25		25
H7617	050	0	1	04	01	H7617_050_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	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	25		25				25		25	25		25	25		25
H7617	050	0	1	04	01	H7617_050_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	25						25			25			25		25
H7617	051	0	1	04	01	H7617_051_0	2			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	0		0				25		25	0		0	0		0
H7617	051	0	1	04	01	H7617_051_0	2			Generic	4	11	1	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	25		25				25		25	25		0	25		25
H7617	051	0	1	04	01	H7617_051_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	051	0	1	04	01	H7617_051_0	2			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	25		25				25		25	25		25	25		25
H7617	051	0	1	04	01	H7617_051_0	2			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	25						25			25			25		25
H7617	052	0	1	04	01	H7617_052_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	0		0				25		25	0		0	0		0
H7617	052	0	1	04	01	H7617_052_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	0		0				25		25	0		0	0		0
H7617	052	0	1	04	01	H7617_052_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	25		25				25		25	25		25	25		25
H7617	052	0	1	04	01	H7617_052_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	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	25		25				25		25	25		25	25		25
H7617	052	0	1	04	01	H7617_052_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	25						25			25			25		25
H7617	053	0	1	04	01	H7617_053_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	0		0				25		25	0		0	0		0
H7617	053	0	1	04	01	H7617_053_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	053	0	1	04	01	H7617_053_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	25		25				25		25	25		25	25		25
H7617	053	0	1	04	01	H7617_053_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	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	25		25				25		25	25		25	25		25
H7617	053	0	1	04	01	H7617_053_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	25						25			25			25		25
H7617	055	0	1	04	01	H7617_055_0	2			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	0		0				25		25	0		0	0		0
H7617	055	0	1	04	01	H7617_055_0	2			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	25		25				25		25	25		0	25		25
H7617	055	0	1	04	01	H7617_055_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	055	0	1	04	01	H7617_055_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H7617	055	0	1	04	01	H7617_055_0	2			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	25						25			25			25		25
H7617	056	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	056	0	1	04	01	H7617_056_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	0		0				25		25	0		0	0		0
H7617	056	0	1	04	01	H7617_056_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	25		25				25		25	25		25	25		25
H7617	056	0	1	04	01	H7617_056_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				32.00	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	25		25				25		25	25		25	25		25
H7617	056	0	1	04	01	H7617_056_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	25						25			25			25		25
H7617	057	0	1	04	01	H7617_057_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	0		0				25		25	0		0	0		0
H7617	057	0	1	04	01	H7617_057_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	057	0	1	04	01	H7617_057_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	25		25				25		25	25		25	25		25
H7617	057	0	1	04	01	H7617_057_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	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	25		25				25		25	25		25	25		25
H7617	057	0	1	04	01	H7617_057_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	25						25			25			25		25
H7617	058	0	1	04	01	H7617_058_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	0		0				25		25	0		0	0		0
H7617	058	0	1	04	01	H7617_058_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	0		0				25		25	0		0	0		0
H7617	058	0	1	04	01	H7617_058_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	25		25				25		25	25		25	25		25
H7617	058	0	1	04	01	H7617_058_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				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		35.00	25		25				25		25	25		25	25		25
H7617	058	0	1	04	01	H7617_058_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	25						25			25			25		25
H7617	059	0	1	04	01	H7617_059_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	0		0				25		25	0		0	0		0
H7617	059	0	1	04	01	H7617_059_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	059	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	059	0	1	04	01	H7617_059_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	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	25		25				25		25	25		25	25		25
H7617	059	0	1	04	01	H7617_059_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	25						25			25			25		25
H7617	060	0	1	04	01	H7617_060_0	2			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	0		0				25		25	0		0	0		0
H7617	060	0	1	04	01	H7617_060_0	2			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	25		25				25		25	25		0	25		25
H7617	060	0	1	04	01	H7617_060_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	060	0	1	04	01	H7617_060_0	2			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	25		25				25		25	25		25	25		25
H7617	060	0	1	04	01	H7617_060_0	2			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	25						25			25			25		25
H7617	061	0	1	04	01	H7617_061_0	2			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	0		0				25		25	0		0	0		0
H7617	061	0	1	04	01	H7617_061_0	2			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	0		0				25		25	0		0	0		0
H7617	061	0	1	04	01	H7617_061_0	2			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	25		25				25		25	25		25	25		25
H7617	061	0	1	04	01	H7617_061_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				34.00	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	25		25				25		25	25		25	25		25
H7617	061	0	1	04	01	H7617_061_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	25						25			25			25		25
H7617	063	0	1	04	01	H7617_063_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	0		0				25		25	0		0	0		0
H7617	063	0	1	04	01	H7617_063_0	3			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	25		25				25		25	25		0	25		25
H7617	063	0	1	04	01	H7617_063_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	35.00		105.00				35.00		105.00	35.00		95.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	063	0	1	04	01	H7617_063_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	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	25		25				25		25	25		25	25		25
H7617	063	0	1	04	01	H7617_063_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	25						25			25			25		25
H7617	064	0	1	04	01	H7617_064_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	0		0				25		25	0		0	0		0
H7617	064	0	1	04	01	H7617_064_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	25		25				25		25	25		0	25		25
H7617	064	0	1	04	01	H7617_064_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	25		25				25		25	25		25	25		25
H7617	064	0	1	04	01	H7617_064_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				93.00	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	25		25				25		25	25		25	25		25
H7617	064	0	1	04	01	H7617_064_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	25						25			25			25		25
H7617	065	0	1	04	01	H7617_065_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	0		0				25		25	0		0	0		0
H7617	065	0	1	04	01	H7617_065_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	065	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	065	0	1	04	01	H7617_065_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	065	0	1	04	01	H7617_065_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	25						25			25			25		25
H7617	066	0	1	04	01	H7617_066_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	0		0				25		25	0		0	0		0
H7617	066	0	1	04	01	H7617_066_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	066	0	1	04	01	H7617_066_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	25		25				25		25	25		25	25		25
H7617	066	0	1	04	01	H7617_066_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				76.00	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	25		25				25		25	25		25	25		25
H7617	066	0	1	04	01	H7617_066_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	25						25			25			25		25
H7617	067	0	1	04	01	H7617_067_0	4		N	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	0		0				25		25	0		0	0		0
H7617	067	0	1	04	01	H7617_067_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	0		0				25		25	0		0	0		0
H7617	067	0	1	04	01	H7617_067_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	067	0	1	04	01	H7617_067_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	067	0	1	04	01	H7617_067_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	25						25			25			25		25
H7617	068	0	1	04	01	H7617_068_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	0		0				25		25	0		0	0		0
H7617	068	0	1	04	01	H7617_068_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	25		25				25		25	25		0	25		25
H7617	068	0	1	04	01	H7617_068_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	25		25				25		25	25		25	25		25
H7617	068	0	1	04	01	H7617_068_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	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	25		25				25		25	25		25	25		25
H7617	068	0	1	04	01	H7617_068_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	25						25			25			25		25
H7617	069	0	1	04	01	H7617_069_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	0		0				25		25	0		0	0		0
H7617	069	0	1	04	01	H7617_069_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	25		25				25		25	25		0	25		25
H7617	069	0	1	04	01	H7617_069_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	25		25				25		25	25		25	25		25
H7617	069	0	1	04	01	H7617_069_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	50		50																								50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	069	0	1	04	01	H7617_069_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	25						25			25			25		25
H7617	070	0	1	04	01	H7617_070_0	2			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	0		0				25		25	0		0	0		0
H7617	070	0	1	04	01	H7617_070_0	2			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	25		25				25		25	25		0	25		25
H7617	070	0	1	04	01	H7617_070_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	070	0	1	04	01	H7617_070_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				96.00	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	25		25				25		25	25		25	25		25
H7617	070	0	1	04	01	H7617_070_0	2			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	25						25			25			25		25
H7617	071	0	1	04	01	H7617_071_0	2			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	0		0				25		25	0		0	0		0
H7617	071	0	1	04	01	H7617_071_0	2			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	071	0	1	04	01	H7617_071_0	2			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	25		25				25		25	25		25	25		25
H7617	071	0	1	04	01	H7617_071_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				54.00	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	25		25				25		25	25		25	25		25
H7617	071	0	1	04	01	H7617_071_0	2			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	25						25			25			25		25
H7617	072	0	1	04	01	H7617_072_0	2			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	0		0				25		25	0		0	0		0
H7617	072	0	1	04	01	H7617_072_0	2			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	25		25				25		25	25		0	25		25
H7617	072	0	1	04	01	H7617_072_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	072	0	1	04	01	H7617_072_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
H7617	072	0	1	04	01	H7617_072_0	2			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	25						25			25			25		25
H7617	074	0	1	04	01	H7617_074_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	0		0				25		25	0		0	0		0
H7617	074	0	1	04	01	H7617_074_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	0		0				25		25	0		0	0		0
H7617	074	0	1	04	01	H7617_074_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	074	0	1	04	01	H7617_074_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	074	0	1	04	01	H7617_074_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	25						25			25			25		25
H7617	075	0	1	04	01	H7617_075_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	0		0				25		25	0		0	0		0
H7617	075	0	1	04	01	H7617_075_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	0		0				25		25	0		0	0		0
H7617	075	0	1	04	01	H7617_075_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	075	0	1	04	01	H7617_075_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	075	0	1	04	01	H7617_075_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	25						25			25			25		25
H7617	076	0	1	04	01	H7617_076_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	0		0				25		25	0		0	0		0
H7617	076	0	1	04	01	H7617_076_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	0		0				25		25	0		0	0		0
H7617	076	0	1	04	01	H7617_076_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	076	0	1	04	01	H7617_076_0	4		N	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	25		25				25		25	25		25	25		25
H7617	076	0	1	04	01	H7617_076_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	25						25			25			25		25
H7617	077	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	077	0	1	04	01	H7617_077_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, Select Care Drugs	9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00	25		25				25		25	25		0	25		25
H7617	077	0	1	04	01	H7617_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	077	0	1	04	01	H7617_077_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	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	25		25				25		25	25		25	25		25
H7617	077	0	1	04	01	H7617_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	25						25			25			25		25
H7617	077	0	1	04	01	H7617_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	0		0				0		0	0		0	0		0
H7617	078	0	1	04	01	H7617_078_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	0		0				25		25	0		0	0		0
H7617	078	0	1	04	01	H7617_078_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, Select Care Drugs	9.00		27.00				20.00		60.00	9.00		0.00	9.00		9.00	25		25				25		25	25		0	25		25
H7617	078	0	1	04	01	H7617_078_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, Select Care Drugs	35.00		105.00				35.00		105.00	35.00		70.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	078	0	1	04	01	H7617_078_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
H7617	078	0	1	04	01	H7617_078_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	25						25			25			25		25
H7617	078	0	1	04	01	H7617_078_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	0		0				0		0	0		0	0		0
H7617	079	0	1	04	01	H7617_079_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	0		0				25		25	0		0	0		0
H7617	079	0	1	04	01	H7617_079_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	079	0	1	04	01	H7617_079_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	25		25				25		25	25		25	25		25
H7617	079	0	1	04	01	H7617_079_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	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	25		25				25		25	25		25	25		25
H7617	079	0	1	04	01	H7617_079_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	25						25			25			25		25
H7617	080	0	1	04	01	H7617_080_0	2			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	0		0				25		25	0		0	0		0
H7617	080	0	1	04	01	H7617_080_0	2			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	25		25				25		25	25		0	25		25
H7617	080	0	1	04	01	H7617_080_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	080	0	1	04	01	H7617_080_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H7617	080	0	1	04	01	H7617_080_0	2			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	25						25			25			25		25
H7617	082	0	1	04	01	H7617_082_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	0		0				25		25	0		0	0		0
H7617	082	0	1	04	01	H7617_082_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	0		0				25		25	0		0	0		0
H7617	082	0	1	04	01	H7617_082_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	082	0	1	04	01	H7617_082_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	082	0	1	04	01	H7617_082_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	25						25			25			25		25
H7617	083	0	1	04	01	H7617_083_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	0		0				25		25	0		0	0		0
H7617	083	0	1	04	01	H7617_083_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	0		0				25		25	0		0	0		0
H7617	083	0	1	04	01	H7617_083_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	083	0	1	04	01	H7617_083_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	083	0	1	04	01	H7617_083_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	25						25			25			25		25
H7617	084	0	1	04	01	H7617_084_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	0		0				25		25	0		0	0		0
H7617	084	0	1	04	01	H7617_084_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	0		0				25		25	0		0	0		0
H7617	084	0	1	04	01	H7617_084_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	084	0	1	04	01	H7617_084_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	084	0	1	04	01	H7617_084_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	25						25			25			25		25
H7617	085	0	1	04	01	H7617_085_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																									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	0		0				25		25	0		0	0		0
H7617	085	0	1	04	01	H7617_085_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	085	0	1	04	01	H7617_085_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	25		25				25		25	25		25	25		25
H7617	085	0	1	04	01	H7617_085_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				63.00	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	25		25				25		25	25		25	25		25
H7617	085	0	1	04	01	H7617_085_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	25						25			25			25		25
H7617	090	0	1	04	01	H7617_090_0	2			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	0		0				25		25	0		0	0		0
H7617	090	0	1	04	01	H7617_090_0	2			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	25		25				25		25	25		0	25		25
H7617	090	0	1	04	01	H7617_090_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	090	0	1	04	01	H7617_090_0	2			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	25		25				25		25	25		25	25		25
H7617	090	0	1	04	01	H7617_090_0	2			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	25						25			25			25		25
H7617	091	0	1	04	01	H7617_091_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	0		0				25		25	0		0	0		0
H7617	091	0	1	04	01	H7617_091_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	091	0	1	04	01	H7617_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	25		25				25		25	25		25	25		25
H7617	091	0	1	04	01	H7617_091_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
H7617	091	0	1	04	01	H7617_091_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	25						25			25			25		25
H7617	092	0	1	04	01	H7617_092_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	0		0				25		25	0		0	0		0
H7617	092	0	1	04	01	H7617_092_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	092	0	1	04	01	H7617_092_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	25		25				25		25	25		25	25		25
H7617	092	0	1	04	01	H7617_092_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				91.00	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	25		25				25		25	25		25	25		25
H7617	092	0	1	04	01	H7617_092_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	25						25			25			25		25
H7617	093	0	1	04	01	H7617_093_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	0		0				25		25	0		0	0		0
H7617	093	0	1	04	01	H7617_093_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	0		0				25		25	0		0	0		0
H7617	093	0	1	04	01	H7617_093_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	25		25				25		25	25		25	25		25
H7617	093	0	1	04	01	H7617_093_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	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	25		25				25		25	25		25	25		25
H7617	093	0	1	04	01	H7617_093_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	25						25			25			25		25
H7617	094	0	1	04	01	H7617_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	0		0				25		25	0		0	0		0
H7617	094	0	1	04	01	H7617_094_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	094	0	1	04	01	H7617_094_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	25		25				25		25	25		25	25		25
H7617	094	0	1	04	01	H7617_094_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	094	0	1	04	01	H7617_094_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	25						25			25			25		25
H7617	095	0	1	04	01	H7617_095_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	0		0				25		25	0		0	0		0
H7617	095	0	1	04	01	H7617_095_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	095	0	1	04	01	H7617_095_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	25		25				25		25	25		25	25		25
H7617	095	0	1	04	01	H7617_095_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	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	095	0	1	04	01	H7617_095_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	25						25			25			25		25
H7617	098	0	1	04	01	H7617_098_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	0		0				25		25	0		0	0		0
H7617	098	0	1	04	01	H7617_098_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	098	0	1	04	01	H7617_098_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	25		25				25		25	25		25	25		25
H7617	098	0	1	04	01	H7617_098_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	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	25		25				25		25	25		25	25		25
H7617	098	0	1	04	01	H7617_098_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	25						25			25			25		25
H7617	100	0	1	04	01	H7617_100_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	0		0				25		25	0		0	0		0
H7617	100	0	1	04	01	H7617_100_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	100	0	1	04	01	H7617_100_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	25		25				25		25	25		25	25		25
H7617	100	0	1	04	01	H7617_100_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
H7617	100	0	1	04	01	H7617_100_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	25						25			25			25		25
H7617	107	0	1	04	01	H7617_107_0	2			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	0		0				25		25	0		0	0		0
H7617	107	0	1	04	01	H7617_107_0	2			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	0		0				25		25	0		0	0		0
H7617	107	0	1	04	01	H7617_107_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	107	0	1	04	01	H7617_107_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				100.00	41		41																								41		41				41		41			41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	107	0	1	04	01	H7617_107_0	2			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	25						25			25			25		25
H7617	109	0	1	04	01	H7617_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	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
H7617	109	0	1	04	01	H7617_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H7617	109	0	1	04	01	H7617_109_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	25		25				25		25	25		25	25		25
H7617	109	0	1	04	01	H7617_109_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	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	25		25				25		25	25		25	25		25
H7617	109	0	1	04	01	H7617_109_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	25						25			25			25		25
H7617	110	0	1	04	01	H7617_110_0	2			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	0		0				25		25	0		0	0		0
H7617	110	0	1	04	01	H7617_110_0	2			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	25		25				25		25	25		0	25		25
H7617	110	0	1	04	01	H7617_110_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	110	0	1	04	01	H7617_110_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				81.00	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	25		25				25		25	25		25	25		25
H7617	110	0	1	04	01	H7617_110_0	2			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	25						25			25			25		25
H7617	111	0	1	04	01	H7617_111_0	2			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	0		0				25		25	0		0	0		0
H7617	111	0	1	04	01	H7617_111_0	2			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	25		25				25		25	25		0	25		25
H7617	111	0	1	04	01	H7617_111_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H7617	111	0	1	04	01	H7617_111_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
H7617	111	0	1	04	01	H7617_111_0	2			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	25						25			25			25		25
H7617	112	0	1	04	01	H7617_112_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	0		0				25		25	0		0	0		0
H7617	112	0	1	04	01	H7617_112_0	3			Generic	4	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									20.00		60.00				1.00		0.00				1.00				1.00		0.03				0.67	0.03	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				20.00		60.00	1.00		0.00	1.00		1.00	25		25				25		25	25		0	25		25
H7617	112	0	1	04	01	H7617_112_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	25		25				25		25	25		25	25		25
H7617	112	0	1	04	01	H7617_112_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	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	25		25				25		25	25		25	25		25
H7617	112	0	1	04	01	H7617_112_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	25						25			25			25		25
H7617	113	0	1	04	01	H7617_113_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	0		0				25		25	0		0	0		0
H7617	113	0	1	04	01	H7617_113_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	0		0				25		25	0		0	0		0
H7617	113	0	1	04	01	H7617_113_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H7617	113	0	1	04	01	H7617_113_0	4		N	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	25		25				25		25	25		25	25		25
H7617	113	0	1	04	01	H7617_113_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	25						25			25			25		25
H7620	001	0	1	01	01	H7620_001_0	10		N	Preferred Generic	4	01	1	2	1	1	110		10	100		1	30		100				2	2			100					14	31	0.00		0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H7620	001	0	1	01	01	H7620_001_0	10		N	Generic	4	01	1	2	2	1	110		10	100		1	30		100				2	2			100					14	31	11.00		33.00																					33.00																	11.00			11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	11.00		33.00						33.00				11.00		11.00	25		25						25				25		25
H7620	001	0	1	01	01	H7620_001_0	10		N	Preferred Brand	4	11	1	1	3	1	110		10	100		1	30		100				2	2			100					14	31				151.29	25		25																				25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H7620	001	0	1	01	01	H7620_001_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	110		10	100		1	30		100				2	2			100					14	31				49.56	26		26																				26																26		26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H7620	001	0	1	01	01	H7620_001_0	10		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							14	31				793.48	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	25						25						25		25
H7620	001	0	1	01	01	H7620_001_0	10		N	Select Care Drugs	4	01	1	2	6	1	110		10	100		1	30		100				1	2			100					14	31	0.00		0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H7635	001	0	1	01	01	H7635_001_0	12		N	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7635	001	0	1	01	01	H7635_001_0	12		N	Generic	4	01	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7635	001	0	1	01	01	H7635_001_0	12		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				37.46	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	25	25	25				25	25	25				25		25
H7635	001	0	1	01	01	H7635_001_0	12		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				53.89	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7635	001	0	1	01	01	H7635_001_0	12		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				455.43	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	25	25	25				25	25	25				25		25
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				88.30	40	40	40																		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		35.00	25	25	25				25	25	25				25		25
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				543.52	30	30	30																		30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7670	002	0	1	01	01	H7670_002_0	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	25	25	25				25	25	25				25		25
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				92.65	40	40	40																		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		35.00	25	25	25				25	25	25				25		25
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				477.61	30	30	30																		30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7678	006	1	1	01	01	H7678_006_1	8		N	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																														
H7678	006	1	1	01	01	H7678_006_1	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7678	006	1	1	01	01	H7678_006_1	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				36.13	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	20	20	20				20	20	20				20		20
H7678	006	1	1	01	01	H7678_006_1	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.41	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		35.00	25	25	25				25	25	25				25		25
H7678	006	1	1	01	01	H7678_006_1	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				496.64	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	25						25						25		25
H7678	006	1	1	01	01	H7678_006_1	8		N	Select Care Drugs	4	01	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																														
H7678	006	2	1	01	01	H7678_006_2	8		N	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																														
H7678	006	2	1	01	01	H7678_006_2	8		N	Generic	4	11	1	2	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31	2.00	4.00	4.00																			2.00	4.00	4.00																2.00				2.00		0.06			0.06			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7678	006	2	1	01	01	H7678_006_2	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				36.13	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	20	20	20				20	20	20				20		20
H7678	006	2	1	01	01	H7678_006_2	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.41	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		35.00	25	25	25				25	25	25				25		25
H7678	006	2	1	01	01	H7678_006_2	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				496.64	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	25						25						25		25
H7678	006	2	1	01	01	H7678_006_2	8		N	Select Care Drugs	4	01	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																														
H7680	001	0	1	01	01	H7680_001_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	001	0	1	01	01	H7680_001_0	7			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	25	25	25						25				25		25
H7680	001	0	1	01	01	H7680_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	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	25	25	25						25				25		25
H7680	001	0	1	01	01	H7680_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	001	0	1	01	01	H7680_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				112.95	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	001	0	1	01	01	H7680_001_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	002	0	1	01	01	H7680_002_0	7			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	002	0	1	01	01	H7680_002_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	12.00	24.00	24.00						24.00				12.00		12.00	25	25	25						25				25		25
H7680	002	0	1	01	01	H7680_002_0	7			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	25	25	25						25				25		25
H7680	002	0	1	01	01	H7680_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				51.08	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	002	0	1	01	01	H7680_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				117.83	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	002	0	1	01	01	H7680_002_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	007	0	1	01	01	H7680_007_0	5		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																														
H7680	007	0	1	01	01	H7680_007_0	5		N	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	25	25	25						25				25		25
H7680	007	0	1	01	01	H7680_007_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				77.91	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						105.00				35.00		35.00	20	20	20						20				20		20
H7680	007	0	1	01	01	H7680_007_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				59.97	47	47	47																				47															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	007	0	1	01	01	H7680_007_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				146.91	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	007	0	1	01	01	H7680_007_0	5		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																														
H7680	009	0	1	01	01	H7680_009_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	009	0	1	01	01	H7680_009_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	12.00	24.00	24.00						24.00				12.00		12.00	25	25	25						25				25		25
H7680	009	0	1	01	01	H7680_009_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				85.60	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	21	21	21						21				21		21
H7680	009	0	1	01	01	H7680_009_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				58.05	49	49	49																				49															49			49								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	009	0	1	01	01	H7680_009_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				150.48	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	009	0	1	01	01	H7680_009_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	011	0	1	01	01	H7680_011_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	011	0	1	01	01	H7680_011_0	6			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	25	25	25						25				25		25
H7680	011	0	1	01	01	H7680_011_0	6			Preferred Brand	4	11	1	2	3	1	111		01	100		1	30	60	100				1	2			100				30		31	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	25	25	25						25				25		25
H7680	011	0	1	01	01	H7680_011_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	011	0	1	01	01	H7680_011_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				128.10	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	011	0	1	01	01	H7680_011_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	012	0	1	01	01	H7680_012_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	012	0	1	01	01	H7680_012_0	6			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	25	25	25						25				25		25
H7680	012	0	1	01	01	H7680_012_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				123.84	25	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	25	25	25						25				25		25
H7680	012	0	1	01	01	H7680_012_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				51.25	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	012	0	1	01	01	H7680_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				144.42	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	012	0	1	01	01	H7680_012_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	014	0	1	01	01	H7680_014_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	014	0	1	01	01	H7680_014_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	25	25	25						25				25		25
H7680	014	0	1	01	01	H7680_014_0	5			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				127.05	25	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	25	25	25						25				25		25
H7680	014	0	1	01	01	H7680_014_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				49.29	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	014	0	1	01	01	H7680_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				140.84	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	014	0	1	01	01	H7680_014_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																														
H7680	015	0	1	01	01	H7680_015_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	015	0	1	01	01	H7680_015_0	6			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	25	25	25						25				25		25
H7680	015	0	1	01	01	H7680_015_0	6			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	25	25	25						25				25		25
H7680	015	0	1	01	01	H7680_015_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	015	0	1	01	01	H7680_015_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				126.07	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	015	0	1	01	01	H7680_015_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	016	0	1	01	01	H7680_016_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	016	0	1	01	01	H7680_016_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	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	25	25	25						25				25		25
H7680	016	0	1	01	01	H7680_016_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	25	25	25						25				25		25
H7680	016	0	1	01	01	H7680_016_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	016	0	1	01	01	H7680_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				121.48	31																																					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	016	0	1	01	01	H7680_016_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																														
H7680	017	0	1	01	01	H7680_017_0	5		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																														
H7680	017	0	1	01	01	H7680_017_0	5		N	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	25	25	25						25				25		25
H7680	017	0	1	01	01	H7680_017_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				69.37	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						105.00				35.00		35.00	19	19	19						19				19		19
H7680	017	0	1	01	01	H7680_017_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				59.81	48	48	48																				48															48			48								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	017	0	1	01	01	H7680_017_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				157.06	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	017	0	1	01	01	H7680_017_0	5		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																														
H7680	018	0	1	01	01	H7680_018_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	018	0	1	01	01	H7680_018_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	100				1	2			100				30		31	12.00	24.00	24.00																					24.00																12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	12.00	24.00	24.00						24.00				12.00		12.00	25	25	25						25				25		25
H7680	018	0	1	01	01	H7680_018_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				74.44	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						105.00				35.00		35.00	20	20	20						20				20		20
H7680	018	0	1	01	01	H7680_018_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				58.10	45	45	45																				45															45			45								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	018	0	1	01	01	H7680_018_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				159.53	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	018	0	1	01	01	H7680_018_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	019	0	1	02	01	H7680_019_0	6			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	019	0	1	02	01	H7680_019_0	6			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	25	25	25						25				25		25
H7680	019	0	1	02	01	H7680_019_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	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	25	25	25						25				25		25
H7680	019	0	1	02	01	H7680_019_0	6			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	019	0	1	02	01	H7680_019_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				125.03	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	019	0	1	02	01	H7680_019_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	020	0	1	01	01	H7680_020_0	5			Preferred Generic	4	01	3	2	1	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	020	0	1	01	01	H7680_020_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	25	25	25						25				25		25
H7680	020	0	1	01	01	H7680_020_0	5			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				108.99	25	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	25	25	25						25				25		25
H7680	020	0	1	01	01	H7680_020_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				61.21	50	50	50																				50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7680	020	0	1	01	01	H7680_020_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				130.62	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H7680	020	0	1	01	01	H7680_020_0	5			Select Care Drugs	4	01	1	2	6	1	111		01	100		1	30	60	100				1	2			100				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7766	001	0	1	04	01	H7766_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	0	0	0				0	0	0				0		0
H7766	001	0	1	04	01	H7766_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7766	001	0	1	04	01	H7766_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				33.00	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	19	19	19				19	19	19				19		19
H7766	001	0	1	04	01	H7766_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	001	0	1	04	01	H7766_001_0	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	25						25						25		25
H7766	002	0	1	04	01	H7766_002_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	0	0	0				0	0	0				0		0
H7766	002	0	1	04	01	H7766_002_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	25	25	25				25	25	25				25		25
H7766	002	0	1	04	01	H7766_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				39.00	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	21	21	21				21	21	21				21		21
H7766	002	0	1	04	01	H7766_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				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	25	25	25				25	25	25				25		25
H7766	002	0	1	04	01	H7766_002_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	25						25						25		25
H7766	004	0	1	04	01	H7766_004_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7766	004	0	1	04	01	H7766_004_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	004	0	1	04	01	H7766_004_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				51.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	004	0	1	04	01	H7766_004_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				72.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	004	0	1	04	01	H7766_004_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7766	004	0	1	04	01	H7766_004_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7766	005	0	1	04	01	H7766_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7766	005	0	1	04	01	H7766_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7766	005	0	1	04	01	H7766_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				33.00	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	19	19	19				19	19	19				19		19
H7766	005	0	1	04	01	H7766_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				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	25	25	25				25	25	25				25		25
H7766	005	0	1	04	01	H7766_005_0	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	25						25						25		25
H7766	006	0	1	04	01	H7766_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	0	0	0				0	0	0				0		0
H7766	006	0	1	04	01	H7766_006_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	25	25	25				25	25	25				25		25
H7766	006	0	1	04	01	H7766_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				39.00	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	21	21	21				21	21	21				21		21
H7766	006	0	1	04	01	H7766_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				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	25	25	25				25	25	25				25		25
H7766	006	0	1	04	01	H7766_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	25						25						25		25
H7766	012	0	1	04	01	H7766_012_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7766	012	0	1	04	01	H7766_012_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7766	012	0	1	04	01	H7766_012_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H7766	012	0	1	04	01	H7766_012_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7766	012	0	1	04	01	H7766_012_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7766	012	0	1	04	01	H7766_012_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7766	013	0	1	04	01	H7766_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7766	013	0	1	04	01	H7766_013_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7766	013	0	1	04	01	H7766_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H7766	013	0	1	04	01	H7766_013_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H7766	013	0	1	04	01	H7766_013_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7766	013	0	1	04	01	H7766_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7766	014	0	1	04	01	H7766_014_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7766	014	0	1	04	01	H7766_014_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7766	014	0	1	04	01	H7766_014_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	014	0	1	04	01	H7766_014_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7766	014	0	1	04	01	H7766_014_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7766	014	0	1	04	01	H7766_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7766	015	0	1	04	01	H7766_015_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7766	015	0	1	04	01	H7766_015_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	015	0	1	04	01	H7766_015_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				48.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	015	0	1	04	01	H7766_015_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				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7766	015	0	1	04	01	H7766_015_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7766	015	0	1	04	01	H7766_015_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																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	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7787	001	0	1	04	01	H7787_001_0	4			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
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					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7787	001	0	1	04	01	H7787_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											63.76	50	50	50				63.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											683.22	29						462.40	29												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	25			25			25			25			25		25
H7849	002	0	1	04	01	H7849_002_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	002	0	1	04	01	H7849_002_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	002	0	1	04	01	H7849_002_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	002	0	1	04	01	H7849_002_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											71.44	50	50	50				63.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	002	0	1	04	01	H7849_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											615.02	30						569.42	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	25			25			25			25			25		25
H7849	015	0	1	04	01	H7849_015_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	015	0	1	04	01	H7849_015_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	015	0	1	04	01	H7849_015_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	015	0	1	04	01	H7849_015_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											69.36	50	50	50				61.25	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	015	0	1	04	01	H7849_015_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											690.05	30						602.44	30												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	25			25			25			25			25		25
H7849	024	0	1	04	01	H7849_024_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	024	0	1	04	01	H7849_024_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	024	0	1	04	01	H7849_024_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	024	0	1	04	01	H7849_024_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											69.75	50	50	50				62.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	024	0	1	04	01	H7849_024_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											645.57	30						557.56	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	029	0	1	04	01	H7849_029_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	029	0	1	04	01	H7849_029_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	029	0	1	04	01	H7849_029_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	029	0	1	04	01	H7849_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		31											53.62	50	50	50				59.18	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	029	0	1	04	01	H7849_029_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											565.59	30						539.74	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	25			25			25			25			25		25
H7849	059	0	1	04	01	H7849_059_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	059	0	1	04	01	H7849_059_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	059	0	1	04	01	H7849_059_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	059	0	1	04	01	H7849_059_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											56.49	50	50	50				58.12	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	059	0	1	04	01	H7849_059_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											550.37	30						526.22	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	065	0	1	04	01	H7849_065_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	065	0	1	04	01	H7849_065_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	065	0	1	04	01	H7849_065_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	065	0	1	04	01	H7849_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		31											89.43	50	50	50				60.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	065	0	1	04	01	H7849_065_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											542.45	30						495.98	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	25			25			25			25			25		25
H7849	070	0	1	04	01	H7849_070_0	6			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	070	0	1	04	01	H7849_070_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	070	0	1	04	01	H7849_070_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	070	0	1	04	01	H7849_070_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											75.46	50	50	50				63.19	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	070	0	1	04	01	H7849_070_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											568.92	25						509.55	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	25			25			25			25			25		25
H7849	077	0	1	04	01	H7849_077_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	077	0	1	04	01	H7849_077_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	077	0	1	04	01	H7849_077_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	077	0	1	04	01	H7849_077_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											62.72	50	50	50				59.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	077	0	1	04	01	H7849_077_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											612.39	30						553.82	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	25			25			25			25			25		25
H7849	080	0	1	04	01	H7849_080_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	080	0	1	04	01	H7849_080_0	5			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					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	080	0	1	04	01	H7849_080_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	080	0	1	04	01	H7849_080_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											78.17	50	50	50				71.93	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	080	0	1	04	01	H7849_080_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											720.99	30						576.44	30												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	25			25			25			25			25		25
H7849	088	0	1	04	01	H7849_088_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	088	0	1	04	01	H7849_088_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	088	0	1	04	01	H7849_088_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	088	0	1	04	01	H7849_088_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											77.56	50	50	50				71.09	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	088	0	1	04	01	H7849_088_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											777.56	30						669.50	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	25			25			25			25			25		25
H7849	102	1	1	04	01	H7849_102_1	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	102	1	1	04	01	H7849_102_1	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	102	1	1	04	01	H7849_102_1	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	1	1	04	01	H7849_102_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.59	50	50	50				52.74	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	1	1	04	01	H7849_102_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											528.86	29						440.04	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	25			25			25			25			25		25
H7849	102	2	1	04	01	H7849_102_2	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	102	2	1	04	01	H7849_102_2	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	102	2	1	04	01	H7849_102_2	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	2	1	04	01	H7849_102_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.59	50	50	50				52.74	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	2	1	04	01	H7849_102_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											528.86	29						440.04	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	25			25			25			25			25		25
H7849	102	3	1	04	01	H7849_102_3	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	102	3	1	04	01	H7849_102_3	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	102	3	1	04	01	H7849_102_3	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	3	1	04	01	H7849_102_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.59	50	50	50				52.74	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	102	3	1	04	01	H7849_102_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											528.86	29						440.04	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	25			25			25			25			25		25
H7849	106	0	1	04	01	H7849_106_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	106	0	1	04	01	H7849_106_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	106	0	1	04	01	H7849_106_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	106	0	1	04	01	H7849_106_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											70.21	50	50	50				71.22	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	106	0	1	04	01	H7849_106_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											658.24	29						547.59	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	113	1	1	04	01	H7849_113_1	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	113	1	1	04	01	H7849_113_1	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	113	1	1	04	01	H7849_113_1	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	1	1	04	01	H7849_113_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.36	50	50	50				61.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	1	1	04	01	H7849_113_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											441.06	25						493.07	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	25			25			25			25			25		25
H7849	113	2	1	04	01	H7849_113_2	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	113	2	1	04	01	H7849_113_2	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	113	2	1	04	01	H7849_113_2	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	2	1	04	01	H7849_113_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.36	50	50	50				61.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	2	1	04	01	H7849_113_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											441.06	25						493.07	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	25			25			25			25			25		25
H7849	113	3	1	04	01	H7849_113_3	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	113	3	1	04	01	H7849_113_3	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	113	3	1	04	01	H7849_113_3	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	3	1	04	01	H7849_113_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.36	50	50	50				61.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	3	1	04	01	H7849_113_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											441.06	25						493.07	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	25			25			25			25			25		25
H7849	113	4	1	04	01	H7849_113_4	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	113	4	1	04	01	H7849_113_4	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	113	4	1	04	01	H7849_113_4	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	4	1	04	01	H7849_113_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											54.36	50	50	50				61.26	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	113	4	1	04	01	H7849_113_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											441.06	25						493.07	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	25			25			25			25			25		25
H7849	114	0	1	04	01	H7849_114_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	114	0	1	04	01	H7849_114_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	114	0	1	04	01	H7849_114_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	114	0	1	04	01	H7849_114_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.03	50	50	50				39.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	114	0	1	04	01	H7849_114_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											300.52	25						337.96	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	25			25			25			25			25		25
H7849	135	0	1	04	01	H7849_135_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	135	0	1	04	01	H7849_135_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	135	0	1	04	01	H7849_135_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	135	0	1	04	01	H7849_135_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											44.82	50	50	50				54.08	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	135	0	1	04	01	H7849_135_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											625.13	30						522.75	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	136	1	1	04	01	H7849_136_1	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	136	1	1	04	01	H7849_136_1	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	136	1	1	04	01	H7849_136_1	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	1	1	04	01	H7849_136_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.12	50	50	50				55.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	1	1	04	01	H7849_136_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											569.48	25						457.05	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	25			25			25			25			25		25
H7849	136	2	1	04	01	H7849_136_2	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	136	2	1	04	01	H7849_136_2	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	136	2	1	04	01	H7849_136_2	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	2	1	04	01	H7849_136_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.12	50	50	50				55.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	2	1	04	01	H7849_136_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											569.48	25						457.05	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	25			25			25			25			25		25
H7849	136	3	1	04	01	H7849_136_3	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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	136	3	1	04	01	H7849_136_3	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	136	3	1	04	01	H7849_136_3	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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	3	1	04	01	H7849_136_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											58.12	50	50	50				55.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	136	3	1	04	01	H7849_136_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											569.48	25						457.05	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	25			25			25			25			25		25
H7849	142	0	1	04	01	H7849_142_0	6			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								9.00	18.00	27.00					0.00	0.00	0.00											9.00	18.00	27.00				0.00	0.00	0.00				9.00				9.00			0.30	0.00		0.30	0.00	0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	9.00	18.00	27.00	0.00	0.00	0.00	9.00	18.00	27.00	0.00	0.00	0.00	9.00		9.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	142	0	1	04	01	H7849_142_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								15.00	30.00	45.00					4.00	8.00	12.00											15.00	30.00	45.00				4.00	8.00	0.00				15.00				15.00			0.50	0.13		0.50	0.13	0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	15.00	30.00	45.00	4.00	8.00	12.00	15.00	30.00	45.00	4.00	8.00	0.00	15.00		15.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	142	0	1	04	01	H7849_142_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	142	0	1	04	01	H7849_142_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											77.76	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	142	0	1	04	01	H7849_142_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											561.08	25						478.83	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	25			25			25			25			25		25
H7849	143	0	1	04	01	H7849_143_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	143	0	1	04	01	H7849_143_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	143	0	1	04	01	H7849_143_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	143	0	1	04	01	H7849_143_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											53.79	50	50	50				49.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	143	0	1	04	01	H7849_143_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											600.45	30						473.46	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	144	0	1	04	01	H7849_144_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	144	0	1	04	01	H7849_144_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	144	0	1	04	01	H7849_144_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	144	0	1	04	01	H7849_144_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.37	50	50	50				54.53	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	144	0	1	04	01	H7849_144_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											620.27	30						518.36	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	25			25			25			25			25		25
H7849	145	0	1	04	01	H7849_145_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	145	0	1	04	01	H7849_145_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	145	0	1	04	01	H7849_145_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	145	0	1	04	01	H7849_145_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											71.70	50	50	50				61.02	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	145	0	1	04	01	H7849_145_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											688.57	30						544.76	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	25			25			25			25			25		25
H7849	146	0	1	04	01	H7849_146_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	146	0	1	04	01	H7849_146_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	146	0	1	04	01	H7849_146_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	146	0	1	04	01	H7849_146_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											80.28	50	50	50				66.43	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	146	0	1	04	01	H7849_146_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											670.54	30						506.08	30												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	25			25			25			25			25		25
H7849	147	0	1	04	01	H7849_147_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	147	0	1	04	01	H7849_147_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	147	0	1	04	01	H7849_147_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	147	0	1	04	01	H7849_147_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											61.95	50	50	50				66.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	147	0	1	04	01	H7849_147_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											560.47	30						596.87	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	25			25			25			25			25		25
H7849	148	0	1	04	01	H7849_148_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	148	0	1	04	01	H7849_148_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	148	0	1	04	01	H7849_148_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	148	0	1	04	01	H7849_148_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.47	50	50	50				82.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	148	0	1	04	01	H7849_148_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											579.47	30						501.46	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	149	0	1	04	01	H7849_149_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	149	0	1	04	01	H7849_149_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	149	0	1	04	01	H7849_149_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	149	0	1	04	01	H7849_149_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.47	50	50	50				82.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	149	0	1	04	01	H7849_149_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											579.47	30						501.46	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	150	0	1	04	01	H7849_150_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	150	0	1	04	01	H7849_150_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	150	0	1	04	01	H7849_150_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	150	0	1	04	01	H7849_150_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											94.47	50	50	50				82.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	150	0	1	04	01	H7849_150_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											579.47	30						501.46	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7849	151	0	1	04	01	H7849_151_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	151	0	1	04	01	H7849_151_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	151	0	1	04	01	H7849_151_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	151	0	1	04	01	H7849_151_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											69.07	50	50	50				73.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	151	0	1	04	01	H7849_151_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											674.60	30						608.85	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	25			25			25			25			25		25
H7849	152	0	1	04	01	H7849_152_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	152	0	1	04	01	H7849_152_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	152	0	1	04	01	H7849_152_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	152	0	1	04	01	H7849_152_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											61.95	50	50	50				66.07	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	152	0	1	04	01	H7849_152_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											560.47	30						596.87	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	25			25			25			25			25		25
H7849	153	0	1	04	01	H7849_153_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											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	153	0	1	04	01	H7849_153_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	153	0	1	04	01	H7849_153_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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	153	0	1	04	01	H7849_153_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											70.98	50	50	50				57.75	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	153	0	1	04	01	H7849_153_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											686.09	30						463.36	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	25			25			25			25			25		25
H7849	154	0	1	04	01	H7849_154_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	154	0	1	04	01	H7849_154_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	154	0	1	04	01	H7849_154_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	154	0	1	04	01	H7849_154_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											74.63	50	50	50				61.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	154	0	1	04	01	H7849_154_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											571.85	30						484.64	30												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	25			25			25			25			25		25
H7849	155	0	1	04	01	H7849_155_0	5			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H7849	155	0	1	04	01	H7849_155_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H7849	155	0	1	04	01	H7849_155_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	155	0	1	04	01	H7849_155_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											78.20	50	50	50				61.82	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7849	155	0	1	04	01	H7849_155_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											553.61	30						471.17	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	009	0	1	04	01	H7917_009_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	009	0	1	04	01	H7917_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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	009	0	1	04	01	H7917_009_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											71.89	50						67.31	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	009	0	1	04	01	H7917_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	010	0	1	04	01	H7917_010_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	010	0	1	04	01	H7917_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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	010	0	1	04	01	H7917_010_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											70.19	50						68.84	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	010	0	1	04	01	H7917_010_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	011	0	1	04	01	H7917_011_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	011	0	1	04	01	H7917_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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	011	0	1	04	01	H7917_011_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											71.78	50						67.44	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	011	0	1	04	01	H7917_011_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	012	0	1	04	01	H7917_012_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	012	0	1	04	01	H7917_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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	012	0	1	04	01	H7917_012_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											68.94	50						69.89	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	012	0	1	04	01	H7917_012_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	013	0	1	04	01	H7917_013_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	013	0	1	04	01	H7917_013_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											71.02	50						75.57	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	013	0	1	04	01	H7917_013_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	014	0	1	04	01	H7917_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								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	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	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	7			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	014	0	1	04	01	H7917_014_0	7			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											64.23	50						66.86	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	014	0	1	04	01	H7917_014_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	015	0	1	04	01	H7917_015_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	015	0	1	04	01	H7917_015_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	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	6			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	015	0	1	04	01	H7917_015_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											67.14	50						65.59	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	015	0	1	04	01	H7917_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	1	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	030	0	1	04	01	H7917_030_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											60.91	50						62.09	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	031	0	1	04	01	H7917_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	031	0	1	04	01	H7917_031_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											56.01	50						57.29	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	031	0	1	04	01	H7917_031_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	032	0	1	04	01	H7917_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	032	0	1	04	01	H7917_032_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											63.10	50						64.10	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	032	0	1	04	01	H7917_032_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	1	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	033	0	1	04	01	H7917_033_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											53.60	50						54.68	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	038	0	1	04	01	H7917_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								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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								15.00	30.00	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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	038	0	1	04	01	H7917_038_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											65.44	50						65.21	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	038	0	1	04	01	H7917_038_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	1	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	040	0	1	04	01	H7917_040_0	6			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											57.07	50						64.06	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	044	0	1	04	01	H7917_044_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	044	0	1	04	01	H7917_044_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	35.00					0.00	0.00	0.00											15.00	30.00	35.00				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																														
H7917	044	0	1	04	01	H7917_044_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	044	0	1	04	01	H7917_044_0	5			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											51.21	50						52.69	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	044	0	1	04	01	H7917_044_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7917	045	0	1	04	01	H7917_045_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	045	0	1	04	01	H7917_045_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	35.00					0.00	0.00	0.00											15.00	30.00	35.00				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																														
H7917	045	0	1	04	01	H7917_045_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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H7917	045	0	1	04	01	H7917_045_0	5			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30								30			30		31											50.93	50						52.75	50												50						50					50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H7917	045	0	1	04	01	H7917_045_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												30							30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H7980	001	0	1	04	01	H7980_001_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	0		0				0		0				0		0
H7980	001	0	1	04	01	H7980_001_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	25		25				0		0				25		25
H7980	001	0	1	04	01	H7980_001_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	25		25				25		25				25		25
H7980	001	0	1	04	01	H7980_001_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	25		25				25		25				25		25
H7980	001	0	1	04	01	H7980_001_0	8			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																														
H7993	001	0	1	01	01	H7993_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	0	0	0				0	0	0				0		0
H7993	001	0	1	01	01	H7993_001_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	0	0	0				0	0	0				0		0
H7993	001	0	1	01	01	H7993_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				31.00	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	20	20	20				20	20	20				20		20
H7993	001	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	001	0	1	01	01	H7993_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7993	002	0	1	01	01	H7993_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	0	0	0				0	0	0				0		0
H7993	002	0	1	01	01	H7993_002_0	6			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	25	25	25				25	25	25				25		25
H7993	002	0	1	01	01	H7993_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				36.00	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	22	22	22				22	22	22				22		22
H7993	002	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	002	0	1	01	01	H7993_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	25						25						25		25
H7993	003	0	1	01	01	H7993_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	0	0	0				0	0	0				0		0
H7993	003	0	1	01	01	H7993_003_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	0	0	0				0	0	0				0		0
H7993	003	0	1	01	01	H7993_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				38.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7993	003	0	1	01	01	H7993_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				70.00	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		35.00	25	25	25				25	25	25				25		25
H7993	003	0	1	01	01	H7993_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H7993	004	0	1	01	01	H7993_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	0	0	0				0	0	0				0		0
H7993	004	0	1	01	01	H7993_004_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	004	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	004	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	004	0	1	01	01	H7993_004_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
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				68.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H7993	007	0	1	01	01	H7993_007_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	0	0	0				0	0	0				0		0
H7993	007	0	1	01	01	H7993_007_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	007	0	1	01	01	H7993_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				43.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7993	007	0	1	01	01	H7993_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				74.00	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		35.00	25	25	25				25	25	25				25		25
H7993	007	0	1	01	01	H7993_007_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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				79.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
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				87.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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	25						25						25		25
H7993	010	0	1	01	01	H7993_010_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	010	0	1	01	01	H7993_010_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	010	0	1	01	01	H7993_010_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	010	0	1	01	01	H7993_010_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	010	0	1	01	01	H7993_010_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	010	0	1	01	01	H7993_010_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	012	0	1	01	01	H7993_012_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	012	0	1	01	01	H7993_012_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	012	0	1	01	01	H7993_012_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	012	0	1	01	01	H7993_012_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	012	0	1	01	01	H7993_012_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	012	0	1	01	01	H7993_012_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	014	0	1	01	01	H7993_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H7993	014	0	1	01	01	H7993_014_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	0	0	0				0	0	0				0		0
H7993	014	0	1	01	01	H7993_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				32.00	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	19	19	19				19	19	19				19		19
H7993	014	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	014	0	1	01	01	H7993_014_0	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	25						25						25		25
H7993	015	0	1	01	01	H7993_015_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	015	0	1	01	01	H7993_015_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	015	0	1	01	01	H7993_015_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	015	0	1	01	01	H7993_015_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	015	0	1	01	01	H7993_015_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	015	0	1	01	01	H7993_015_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	017	0	1	01	01	H7993_017_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	017	0	1	01	01	H7993_017_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	017	0	1	01	01	H7993_017_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	017	0	1	01	01	H7993_017_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	017	0	1	01	01	H7993_017_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	017	0	1	01	01	H7993_017_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	019	0	1	01	01	H7993_019_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	0	0	0				0	0	0				0		0
H7993	019	0	1	01	01	H7993_019_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	0	0	0				0	0	0				0		0
H7993	019	0	1	01	01	H7993_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				31.00	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	19	19	19				19	19	19				19		19
H7993	019	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	019	0	1	01	01	H7993_019_0	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	25						25						25		25
H7993	021	0	1	01	01	H7993_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	Preferred Generic, 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	0	0				0	0	0				0		0
H7993	021	0	1	01	01	H7993_021_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	25	25	25				25	25	25				25		25
H7993	021	0	1	01	01	H7993_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				39.00	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	21	21	21				21	21	21				21		21
H7993	021	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	021	0	1	01	01	H7993_021_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	25						25						25		25
H7993	023	0	1	01	01	H7993_023_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	023	0	1	01	01	H7993_023_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7993	023	0	1	01	01	H7993_023_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H7993	023	0	1	01	01	H7993_023_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	023	0	1	01	01	H7993_023_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	023	0	1	01	01	H7993_023_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	024	0	1	01	01	H7993_024_0	5			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	024	0	1	01	01	H7993_024_0	5			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7993	024	0	1	01	01	H7993_024_0	5			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	024	0	1	01	01	H7993_024_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				73.00	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		35.00	25	25	25				25	25	25				25		25
H7993	024	0	1	01	01	H7993_024_0	5			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	024	0	1	01	01	H7993_024_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	027	0	1	01	01	H7993_027_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	0	0	0				0	0	0				0		0
H7993	027	0	1	01	01	H7993_027_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	027	0	1	01	01	H7993_027_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				32.00	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	20	20	20				20	20	20				20		20
H7993	027	0	1	01	01	H7993_027_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				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	25	25	25				25	25	25				25		25
H7993	027	0	1	01	01	H7993_027_0	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	25						25						25		25
H7993	028	0	1	01	01	H7993_028_0	5			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	028	0	1	01	01	H7993_028_0	5			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7993	028	0	1	01	01	H7993_028_0	5			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H7993	028	0	1	01	01	H7993_028_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				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	028	0	1	01	01	H7993_028_0	5			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	028	0	1	01	01	H7993_028_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	029	0	1	01	01	H7993_029_0	5			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	029	0	1	01	01	H7993_029_0	5			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7993	029	0	1	01	01	H7993_029_0	5			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	029	0	1	01	01	H7993_029_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				73.00	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		35.00	25	25	25				25	25	25				25		25
H7993	029	0	1	01	01	H7993_029_0	5			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	029	0	1	01	01	H7993_029_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	030	0	1	01	01	H7993_030_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	030	0	1	01	01	H7993_030_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H7993	030	0	1	01	01	H7993_030_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H7993	030	0	1	01	01	H7993_030_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	030	0	1	01	01	H7993_030_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	030	0	1	01	01	H7993_030_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	031	0	1	01	01	H7993_031_0	5			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	031	0	1	01	01	H7993_031_0	5			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7993	031	0	1	01	01	H7993_031_0	5			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	031	0	1	01	01	H7993_031_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				73.00	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		35.00	25	25	25				25	25	25				25		25
H7993	031	0	1	01	01	H7993_031_0	5			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	031	0	1	01	01	H7993_031_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	033	0	1	01	01	H7993_033_0	5			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	033	0	1	01	01	H7993_033_0	5			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7993	033	0	1	01	01	H7993_033_0	5			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	033	0	1	01	01	H7993_033_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				73.00	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		35.00	25	25	25				25	25	25				25		25
H7993	033	0	1	01	01	H7993_033_0	5			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	033	0	1	01	01	H7993_033_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	034	0	1	01	01	H7993_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	034	0	1	01	01	H7993_034_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	034	0	1	01	01	H7993_034_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				32.00	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	19	19	19				19	19	19				19		19
H7993	034	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	034	0	1	01	01	H7993_034_0	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	25						25						25		25
H7993	035	0	1	01	01	H7993_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H7993	035	0	1	01	01	H7993_035_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	25	25	25				25	25	25				25		25
H7993	035	0	1	01	01	H7993_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				39.00	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	21	21	21				21	21	21				21		21
H7993	035	0	1	01	01	H7993_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				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	25	25	25				25	25	25				25		25
H7993	035	0	1	01	01	H7993_035_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	25						25						25		25
H7993	036	0	1	01	01	H7993_036_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H7993	036	0	1	01	01	H7993_036_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H7993	036	0	1	01	01	H7993_036_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	036	0	1	01	01	H7993_036_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H7993	036	0	1	01	01	H7993_036_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	036	0	1	01	01	H7993_036_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	037	0	1	01	01	H7993_037_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	037	0	1	01	01	H7993_037_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	037	0	1	01	01	H7993_037_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	037	0	1	01	01	H7993_037_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	037	0	1	01	01	H7993_037_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	037	0	1	01	01	H7993_037_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	038	0	1	01	01	H7993_038_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	038	0	1	01	01	H7993_038_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	038	0	1	01	01	H7993_038_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	038	0	1	01	01	H7993_038_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	038	0	1	01	01	H7993_038_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	038	0	1	01	01	H7993_038_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	040	0	1	01	01	H7993_040_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	040	0	1	01	01	H7993_040_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	040	0	1	01	01	H7993_040_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	040	0	1	01	01	H7993_040_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	040	0	1	01	01	H7993_040_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	040	0	1	01	01	H7993_040_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	041	0	1	01	01	H7993_041_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H7993	041	0	1	01	01	H7993_041_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	041	0	1	01	01	H7993_041_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	041	0	1	01	01	H7993_041_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	041	0	1	01	01	H7993_041_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H7993	041	0	1	01	01	H7993_041_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H7993	046	0	1	01	01	H7993_046_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	0	0	0				0	0	0				0		0
H7993	046	0	1	01	01	H7993_046_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	0	0	0				0	0	0				0		0
H7993	046	0	1	01	01	H7993_046_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	25	25	25				25	25	25				25		25
H7993	046	0	1	01	01	H7993_046_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				97.00	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		35.00	25	25	25				25	25	25				25		25
H7993	046	0	1	01	01	H7993_046_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	25						25						25		25
H7993	048	0	1	01	01	H7993_048_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	0	0	0				0	0	0				0		0
H7993	048	0	1	01	01	H7993_048_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	0	0	0				0	0	0				0		0
H7993	048	0	1	01	01	H7993_048_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H7993	048	0	1	01	01	H7993_048_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				69.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H7993	048	0	1	01	01	H7993_048_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	25						25						25		25
H8003	001	0	1	04	01	H8003_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	001	0	1	04	01	H8003_001_0	6			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	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	001	0	1	04	01	H8003_001_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											82.64	25	25	25				82.64	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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8003	001	0	1	04	01	H8003_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		31											97.85	30	30	30				81.54	25	25	25				25	25	25															30			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8003	001	0	1	04	01	H8003_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1098.71	28						1098.71	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	25			25			25						25		25
H8003	001	0	1	04	01	H8003_001_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	002	0	1	04	01	H8003_002_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	002	0	1	04	01	H8003_002_0	6			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	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	002	0	1	04	01	H8003_002_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											85.49	25	25	25				85.49	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8003	002	0	1	04	01	H8003_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		31											69.47	30	30	30				57.89	25	25	25				25	25	25															30			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8003	002	0	1	04	01	H8003_002_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1009.93	28						1009.93	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	25			25			25						25		25
H8003	002	0	1	04	01	H8003_002_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	003	0	1	04	01	H8003_003_0	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	003	0	1	04	01	H8003_003_0	6			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	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	003	0	1	04	01	H8003_003_0	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											91.05	25	25	25				91.05	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8003	003	0	1	04	01	H8003_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		31											80.93	30	30	30				67.44	25	25	25				25	25	25															30			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8003	003	0	1	04	01	H8003_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1141.19	28						1141.19	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	25			25			25						25		25
H8003	003	0	1	04	01	H8003_003_0	6			Select Care Drugs	4	01	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	004	0	1	04	01	H8003_004_0	4			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	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					5.00	10.00	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	004	0	1	04	01	H8003_004_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											83.06	25	25	25				66.45	20	20	20				20	20	20															25			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	25	25	25	20	20	20	20	20	20				25		20
H8003	004	0	1	04	01	H8003_004_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											55.19	30	30	30				51.51	28	28	28				28	28	28															30			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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8003	004	0	1	04	01	H8003_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											1147.23	25						1147.23	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	25			25			25						25		25
H8003	004	0	1	04	01	H8003_004_0	4			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	4			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	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					5.00	10.00	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	005	0	1	04	01	H8003_005_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											85.65	25	25	25				68.52	20	20	20				20	20	20															25			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	25	25	25	20	20	20	20	20	20				25		20
H8003	005	0	1	04	01	H8003_005_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											77.28	30	30	30				72.13	28	28	28				28	28	28															30			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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8003	005	0	1	04	01	H8003_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											974.89	25						974.89	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	25			25			25						25		25
H8003	005	0	1	04	01	H8003_005_0	4			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	5			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	5			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	15.00					5.00	10.00	15.00																10.00				5.00			0.33	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8003	006	0	1	04	01	H8003_006_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											88.38	25	25	25				70.70	20	20	20				20	20	20															25			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	25	25	25	20	20	20	20	20	20				25		20
H8003	006	0	1	04	01	H8003_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		31											61.00	30	30	30				56.94	28	28	28				28	28	28															30			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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8003	006	0	1	04	01	H8003_006_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											801.40	25						801.40	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	25			25			25						25		25
H8003	006	0	1	04	01	H8003_006_0	5			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	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																														
H8010	002	0	1	01	01	H8010_002_0	7			Generic	4	11	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																														
H8010	002	0	1	01	01	H8010_002_0	7			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	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H8010	002	0	1	01	01	H8010_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01	100		1	30	60	100				1	2			100				30		31	100.00	200.00	300.00																					300.00																100.00				100.00		3.33						3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00						105.00				35.00		35.00	25	25	25						25				25		25
H8010	002	0	1	01	01	H8010_002_0	7			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	25	25	25						25				25		25
H8010	003	0	1	01	01	H8010_003_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																														
H8010	003	0	1	01	01	H8010_003_0	6			Generic	4	11	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																														
H8010	003	0	1	01	01	H8010_003_0	6			Preferred Brand	4	11	1	1	3	1	111		01	100		1	30	60	100				1	2			100				30		31				41.99	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	25	25	25						25				25		25
H8010	003	0	1	01	01	H8010_003_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	100		1	30	60	100				1	2			100				30		31				75.44	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	25	25	25						25				25		25
H8010	003	0	1	01	01	H8010_003_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	25	25	25						25				25		25
H8051	001	0	1	01	01	H8051_001_0	10		N	Preferred Generic	4	01	1	2	1	1	110		10	100		1	30		100				2	2			100					14	31	0.00		0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H8051	001	0	1	01	01	H8051_001_0	10		N	Generic	4	11	1	1	2	1	110		10	100		1	30		100				2	2			100					14	31				9.58	25		25																				25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8051	001	0	1	01	01	H8051_001_0	10		N	Preferred Brand	4	10	1	1	3	1	110		10	100		1	30		100				2	2			100					14	31				150.36	25		25																				25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8051	001	0	1	01	01	H8051_001_0	10		N	Non-Preferred Drug	4	11	1	1	4	1	110		10	100		1	30		100				2	2			100					14	31				49.76	25		25																				25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8051	001	0	1	01	01	H8051_001_0	10		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							14	31				733.04	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	25						25						25		25
H8051	001	0	1	01	01	H8051_001_0	10		N	Select Care Drugs	4	01	1	2	6	1	110		10	100		1	30		100				1	2			100					14	31	0.00		0.00																					0.00																	0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H8133	001	0	1	01	01	H8133_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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	001	0	1	01	01	H8133_001_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	001	0	1	01	01	H8133_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											47.53	20	20	20				46.68	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8133	001	0	1	01	01	H8133_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											77.39	42	42	42				76.52	38	38	38										42	42	42				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	001	0	1	01	01	H8133_001_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											619.23	27						664.79	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8133	005	0	1	01	01	H8133_005_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	005	0	1	01	01	H8133_005_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	005	0	1	01	01	H8133_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											55.77	22	22	22				43.83	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	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22	18	18	18	22	22	22	18	18	18	22		22
H8133	005	0	1	01	01	H8133_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											83.16	41	41	41				88.51	39	39	39										41	41	41				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8133	005	0	1	01	01	H8133_005_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											706.69	27						617.54	27												27						27					27			27								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	25	25	25	25	25	25	25	25	25				25		25
H8142	001	0	1	02	01	H8142_001_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
H8142	001	0	1	02	01	H8142_001_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											80.04	35	35	35				80.04	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8142	002	0	1	02	01	H8142_002_0	11			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	25	25	25	25	25	25	25	25	25				25		25
H8142	002	0	1	02	01	H8142_002_0	11			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								15.00	30.00	45.00					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	25	25	25	25	25	25	25	25	25				25		25
H8142	002	0	1	02	01	H8142_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								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	25	25	25	25	25	25	25	25	25				25		25
H8142	002	0	1	02	01	H8142_002_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											70.10	35	35	35				70.10	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8142	002	0	1	02	01	H8142_002_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8142	003	0	1	02	01	H8142_003_0	11			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	25	25	25	25	25	25	25	25	25				25		25
H8142	003	0	1	02	01	H8142_003_0	11			Generic	4	11	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	25	25	25	25	25	25	25	25	25				25		25
H8142	003	0	1	02	01	H8142_003_0	11			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	25	25	25	25	25	25	25	25	25				25		25
H8142	003	0	1	02	01	H8142_003_0	11			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											66.03	35	35	35				66.03	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	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8142	003	0	1	02	01	H8142_003_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	007	0	1	02	01	H8142_007_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	10.00	20.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00				10.00		10.00	25	25	25	25	25	25	25	25	25				25		25
H8142	007	0	1	02	01	H8142_007_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					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	25	25	25	25	25	25	25	25	25				25		25
H8142	007	0	1	02	01	H8142_007_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	25	25	25	25	25	25	25	25	25				25		25
H8142	007	0	1	02	01	H8142_007_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											78.58	35	35	35				78.58	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	70.00	35.00	70.00	70.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8142	007	0	1	02	01	H8142_007_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8145	004	0	1	09	04	H8145_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	0		0				25		25	0		0	0		0
H8145	004	0	1	09	04	H8145_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	25		25				25		25	25		0	25		25
H8145	004	0	1	09	04	H8145_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	25		25				25		25	25		25	25		25
H8145	004	0	1	09	04	H8145_004_0	4			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				55.00	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	25		25				25		25	25		25	25		25
H8145	004	0	1	09	04	H8145_004_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8145	006	0	1	09	04	H8145_006_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	0		0				25		25	0		0	0		0
H8145	006	0	1	09	04	H8145_006_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H8145	006	0	1	09	04	H8145_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	25		25				25		25	25		25	25		25
H8145	006	0	1	09	04	H8145_006_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				60.00	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	25		25				25		25	25		25	25		25
H8145	006	0	1	09	04	H8145_006_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	25						25			25			25		25
H8145	032	0	1	09	04	H8145_032_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	0		0				25		25	0		0	0		0
H8145	032	0	1	09	04	H8145_032_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H8145	032	0	1	09	04	H8145_032_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	25		25				25		25	25		25	25		25
H8145	032	0	1	09	04	H8145_032_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	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	25		25				25		25	25		25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8145	052	0	1	09	04	H8145_052_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	0		0				25		25	0		0	0		0
H8145	052	0	1	09	04	H8145_052_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H8145	052	0	1	09	04	H8145_052_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	25		25				25		25	25		25	25		25
H8145	052	0	1	09	04	H8145_052_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	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8145	069	0	1	09	04	H8145_069_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	0		0				25		25	0		0	0		0
H8145	069	0	1	09	04	H8145_069_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
H8145	069	0	1	09	04	H8145_069_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	25		25				25		25	25		25	25		25
H8145	069	0	1	09	04	H8145_069_0	3			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																								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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				79.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8145	091	0	1	09	04	H8145_091_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	0		0				25		25	0		0	0		0
H8145	091	0	1	09	04	H8145_091_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	25		25				25		25	25		0	25		25
H8145	091	0	1	09	04	H8145_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	25		25				25		25	25		25	25		25
H8145	091	0	1	09	04	H8145_091_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	25		25				25		25	25		25	25		25
H8145	091	0	1	09	04	H8145_091_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8166	005	0	1	04	01	H8166_005_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																														
H8166	005	0	1	04	01	H8166_005_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								15.00		45.00					3.00		9.00													45.00						7.00				15.00				15.00			0.48	0.10				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8166	005	0	1	04	01	H8166_005_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											77.21	21		21				77.21	21		21												21						21			21			21								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H8166	005	0	1	04	01	H8166_005_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											73.98	25		25				73.98	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	20		20	20		20			20			20	20		20
H8166	005	0	1	04	01	H8166_005_0	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																														
H8166	006	0	1	04	01	H8166_006_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																														
H8166	006	0	1	04	01	H8166_006_0	6			Generic	4	01	1	2	2	1		110	01		100	1				31		100	1	2						100	31		31								20.00		60.00					3.00		9.00													60.00						7.00				20.00				20.00			0.65	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8166	006	0	1	04	01	H8166_006_0	6			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											73.54	20		20				73.54	20		20												20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	20		20	20		20			20			20	20		20
H8166	006	0	1	04	01	H8166_006_0	6			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											73.98	25		25				73.98	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	20		20	20		20			20			20	20		20
H8166	006	0	1	04	01	H8166_006_0	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																														
H8173	001	0	1	01	01	H8173_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	0	0	0				0	0	0				0		0
H8173	001	0	1	01	01	H8173_001_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																			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	25	25	25				25	25	25				25		25
H8173	001	0	1	01	01	H8173_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				83.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H8173	001	0	1	01	01	H8173_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				104.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	001	0	1	01	01	H8173_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	25						25						25		25
H8173	007	0	1	01	01	H8173_007_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	0	0	0				0	0	0				0		0
H8173	007	0	1	01	01	H8173_007_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																			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	25	25	25				25	25	25				25		25
H8173	007	0	1	01	01	H8173_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				56.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H8173	007	0	1	01	01	H8173_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				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	25	25	25				25	25	25				25		25
H8173	007	0	1	01	01	H8173_007_0	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	25						25						25		25
H8173	011	0	1	01	01	H8173_011_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	0	0	0				0	0	0				0		0
H8173	011	0	1	01	01	H8173_011_0	6			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	25	25	25				25	25	25				25		25
H8173	011	0	1	01	01	H8173_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				99.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	011	0	1	01	01	H8173_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				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	25	25	25				25	25	25				25		25
H8173	011	0	1	01	01	H8173_011_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	25						25						25		25
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	0	0	0				0	0	0				0		0
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	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	25	25	25				25	25	25				25		25
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				58.00	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	22	22	22				22	22	22				22		22
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				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	25	25	25				25	25	25				25		25
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	25						25						25		25
H8173	014	0	1	01	01	H8173_014_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																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8173	014	0	1	01	01	H8173_014_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H8173	014	0	1	01	01	H8173_014_0	6			Preferred Brand	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	014	0	1	01	01	H8173_014_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				104.00	47	47	47																		47	47	47															47			47								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	014	0	1	01	01	H8173_014_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8173	014	0	1	01	01	H8173_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8173	016	0	1	01	01	H8173_016_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	0	0	0				0	0	0				0		0
H8173	016	0	1	01	01	H8173_016_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																			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	25	25	25				25	25	25				25		25
H8173	016	0	1	01	01	H8173_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				61.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H8173	016	0	1	01	01	H8173_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				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	25	25	25				25	25	25				25		25
H8173	016	0	1	01	01	H8173_016_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8173	019	0	1	01	01	H8173_019_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	0	0	0				0	0	0				0		0
H8173	019	0	1	01	01	H8173_019_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	25	25	25				25	25	25				25		25
H8173	019	0	1	01	01	H8173_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				61.00	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	22	22	22				22	22	22				22		22
H8173	019	0	1	01	01	H8173_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				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	25	25	25				25	25	25				25		25
H8173	019	0	1	01	01	H8173_019_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	25						25						25		25
H8173	020	0	1	01	01	H8173_020_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H8173	020	0	1	01	01	H8173_020_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8173	020	0	1	01	01	H8173_020_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H8173	020	0	1	01	01	H8173_020_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				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	25	25	25				25	25	25				25		25
H8173	020	0	1	01	01	H8173_020_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	25						25						25		25
H8173	021	0	1	01	01	H8173_021_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	0	0	0				0	0	0				0		0
H8173	021	0	1	01	01	H8173_021_0	6			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	25	25	25				25	25	25				25		25
H8173	021	0	1	01	01	H8173_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				34.00	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	21	21	21				21	21	21				21		21
H8173	021	0	1	01	01	H8173_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				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	25	25	25				25	25	25				25		25
H8173	021	0	1	01	01	H8173_021_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	25						25						25		25
H8173	022	0	1	01	01	H8173_022_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8173	022	0	1	01	01	H8173_022_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8173	022	0	1	01	01	H8173_022_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	022	0	1	01	01	H8173_022_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H8173	022	0	1	01	01	H8173_022_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8173	022	0	1	01	01	H8173_022_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8173	023	0	1	01	01	H8173_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H8173	023	0	1	01	01	H8173_023_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8173	023	0	1	01	01	H8173_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				32.00	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	20	20	20				20	20	20				20		20
H8173	023	0	1	01	01	H8173_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				95.00	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		35.00	25	25	25				25	25	25				25		25
H8173	023	0	1	01	01	H8173_023_0	6			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	25						25						25		25
H8173	024	0	1	01	01	H8173_024_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8173	024	0	1	01	01	H8173_024_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H8173	024	0	1	01	01	H8173_024_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H8173	024	0	1	01	01	H8173_024_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	024	0	1	01	01	H8173_024_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8173	024	0	1	01	01	H8173_024_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8173	025	0	1	01	01	H8173_025_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8173	025	0	1	01	01	H8173_025_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8173	025	0	1	01	01	H8173_025_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	025	0	1	01	01	H8173_025_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H8173	025	0	1	01	01	H8173_025_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8173	025	0	1	01	01	H8173_025_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8173	027	0	1	01	01	H8173_027_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8173	027	0	1	01	01	H8173_027_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8173	027	0	1	01	01	H8173_027_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8173	027	0	1	01	01	H8173_027_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H8173	027	0	1	01	01	H8173_027_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8173	027	0	1	01	01	H8173_027_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8176	004	1	1	01	01	H8176_004_1	9		N	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																														
H8176	004	1	1	01	01	H8176_004_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.22	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8176	004	1	1	01	01	H8176_004_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.46	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	20	20	20				20	20	20				20		20
H8176	004	1	1	01	01	H8176_004_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.32	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		35.00	25	25	25				25	25	25				25		25
H8176	004	1	1	01	01	H8176_004_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				560.06	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	25						25						25		25
H8176	004	1	1	01	01	H8176_004_1	9		N	Select Care Drugs	4	01	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																														
H8176	004	2	1	01	01	H8176_004_2	9		N	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																														
H8176	004	2	1	01	01	H8176_004_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				5.22	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8176	004	2	1	01	01	H8176_004_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				37.46	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	20	20	20				20	20	20				20		20
H8176	004	2	1	01	01	H8176_004_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				60.32	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		35.00	25	25	25				25	25	25				25		25
H8176	004	2	1	01	01	H8176_004_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				560.06	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	25						25						25		25
H8176	004	2	1	01	01	H8176_004_2	9		N	Select Care Drugs	4	01	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																														
H8181	001	0	1	04	01	H8181_001_0	7			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	0	0	0				25	25	25	25	25	0	0		0
H8181	001	0	1	04	01	H8181_001_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	14.00	28.00	42.00																									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	25	25	25				25	25	25	25	25	0	25		25
H8181	001	0	1	04	01	H8181_001_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									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	25	25	25				25	25	25	25	25	25	25		25
H8181	001	0	1	04	01	H8181_001_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	100.00	200.00	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	25	25	25				25	25	25	25	25	25	25		25
H8181	001	0	1	04	01	H8181_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1009.53	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8181	002	0	1	04	01	H8181_002_0	7			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	0	0	0				25	25	25	25	25	0	0		0
H8181	002	0	1	04	01	H8181_002_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	14.00	28.00	42.00																									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	25	25	25				25	25	25	25	25	0	25		25
H8181	002	0	1	04	01	H8181_002_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									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	25	25	25				25	25	25	25	25	25	25		25
H8181	002	0	1	04	01	H8181_002_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	200.00	290.00				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	25	25	25				25	25	25	25	25	25	25		25
H8181	002	0	1	04	01	H8181_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				1057.39	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8181	003	0	1	04	01	H8181_003_0	7			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	0	0	0				25	25	25	25	25	0	0		0
H8181	003	0	1	04	01	H8181_003_0	7			Generic	4	01	1	2	2	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	14.00	28.00	42.00																									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	25	25	25				25	25	25	25	25	0	25		25
H8181	003	0	1	04	01	H8181_003_0	7			Preferred Brand	4	11	1	2	3	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	47.00	94.00	141.00																									47.00	94.00	141.00				47.00	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	25	25	25				25	25	25	25	25	25	25		25
H8181	003	0	1	04	01	H8181_003_0	7			Non-Preferred Drug	4	11	1	2	4	1	111		01		111	1	30	60	100				1	2				30	60	100	30		31	100.00	200.00	300.00																									100.00	200.00	300.00				100.00	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	25	25	25				25	25	25	25	25	25	25		25
H8181	003	0	1	04	01	H8181_003_0	7			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31				998.61	28																										28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8189	001	0	1	02	01	H8189_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	001	0	1	02	01	H8189_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	001	0	1	02	01	H8189_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											97.68	20	20	20				97.68	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H8189	001	0	1	02	01	H8189_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H8189	001	0	1	02	01	H8189_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	001	0	1	02	01	H8189_001_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	007	0	1	02	01	H8189_007_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	007	0	1	02	01	H8189_007_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	007	0	1	02	01	H8189_007_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											96.17	25	25	25				96.17	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H8189	007	0	1	02	01	H8189_007_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H8189	007	0	1	02	01	H8189_007_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	007	0	1	02	01	H8189_007_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								8.00	16.00	24.00					0.00	0.00	0.00												16.00	24.00					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																														
H8189	008	0	1	02	01	H8189_008_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H8189	008	0	1	02	01	H8189_008_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H8189	008	0	1	02	01	H8189_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											121.84	25	25	25				121.84	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H8189	008	0	1	02	01	H8189_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											58.71	35	35	35				58.71	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H8189	008	0	1	02	01	H8189_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8189	008	0	1	02	01	H8189_008_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8211	001	0	1	04	01	H8211_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	001	0	1	04	01	H8211_001_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	001	0	1	04	01	H8211_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8211	001	0	1	04	01	H8211_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	001	0	1	04	01	H8211_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				350.00	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	25						25			25			25		25
H8211	006	0	1	04	01	H8211_006_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	006	0	1	04	01	H8211_006_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	006	0	1	04	01	H8211_006_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8211	006	0	1	04	01	H8211_006_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	006	0	1	04	01	H8211_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				371.00	27																										27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	007	0	1	04	01	H8211_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	007	0	1	04	01	H8211_007_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	007	0	1	04	01	H8211_007_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8211	007	0	1	04	01	H8211_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	007	0	1	04	01	H8211_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				349.00	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	25						25			25			25		25
H8211	009	0	1	04	01	H8211_009_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	009	0	1	04	01	H8211_009_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	009	0	1	04	01	H8211_009_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H8211	009	0	1	04	01	H8211_009_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				68.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	009	0	1	04	01	H8211_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				357.00	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	25						25			25			25		25
H8211	011	0	1	04	01	H8211_011_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	011	0	1	04	01	H8211_011_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	011	0	1	04	01	H8211_011_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8211	011	0	1	04	01	H8211_011_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	011	0	1	04	01	H8211_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				326.00	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	25						25			25			25		25
H8211	012	0	1	04	01	H8211_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																														
H8211	012	0	1	04	01	H8211_012_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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8211	012	0	1	04	01	H8211_012_0	6			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				32.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H8211	012	0	1	04	01	H8211_012_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				54.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8211	012	0	1	04	01	H8211_012_0	6			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				315.00	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	25						25			25			25		25
H8212	001	0	1	01	01	H8212_001_0	9		N	Preferred Generic	4	01	1	1	1	1	111		01	101		1	30	60	100				1	2		60	100				30		31				4.68	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8212	001	0	1	01	01	H8212_001_0	9		N	Generic	4	01	1	1	2	1	111		01	101		1	30	60	100				1	2		60	100				30		31				13.29	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H8212	001	0	1	01	01	H8212_001_0	9		N	Preferred Brand	4	10	1	1	3	1	111		01	101		1	30	60	100				1	2		60	100				30		31				103.05	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H8212	001	0	1	01	01	H8212_001_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	101		1	30	60	100				1	2		60	100				30		31				23.66	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00					70.00	105.00				35.00		35.00	25	25	25					25	25				25		25
H8212	001	0	1	01	01	H8212_001_0	9		N	Specialty Tier	4	11	1	1	5	1	111		01	101		1	30	60	100				1	2		60	100				30		31				556.10	25	25	25																			25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8212	001	0	1	01	01	H8212_001_0	9		N	Select Care Drugs	4	01	1	2	6	1	111		01	101		1	30	60	100				1	2		60	100				30		31	0.00	0.00	0.00																				0.00	0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8320	001	0	1	04	01	H8320_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	0	0	0				0	0	0				0		0
H8320	001	0	1	04	01	H8320_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8320	001	0	1	04	01	H8320_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				33.00	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	19	19	19				19	19	19				19		19
H8320	001	0	1	04	01	H8320_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				60.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8320	001	0	1	04	01	H8320_001_0	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	25						25						25		25
H8320	002	0	1	04	01	H8320_002_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	0	0	0				0	0	0				0		0
H8320	002	0	1	04	01	H8320_002_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	25	25	25				25	25	25				25		25
H8320	002	0	1	04	01	H8320_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				39.00	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	21	21	21				21	21	21				21		21
H8320	002	0	1	04	01	H8320_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				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	25	25	25				25	25	25				25		25
H8320	002	0	1	04	01	H8320_002_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	25						25						25		25
H8320	003	0	1	04	01	H8320_003_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H8320	003	0	1	04	01	H8320_003_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8320	003	0	1	04	01	H8320_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				33.00	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	19	19	19				19	19	19				19		19
H8320	003	0	1	04	01	H8320_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				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	25	25	25				25	25	25				25		25
H8320	003	0	1	04	01	H8320_003_0	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	25						25						25		25
H8320	004	0	1	04	01	H8320_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8320	004	0	1	04	01	H8320_004_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	25	25	25				25	25	25				25		25
H8320	004	0	1	04	01	H8320_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				39.00	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	21	21	21				21	21	21				21		21
H8320	004	0	1	04	01	H8320_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				65.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8320	004	0	1	04	01	H8320_004_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	25						25						25		25
H8320	005	0	1	04	01	H8320_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H8320	005	0	1	04	01	H8320_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8320	005	0	1	04	01	H8320_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				33.00	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	19	19	19				19	19	19				19		19
H8320	005	0	1	04	01	H8320_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				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	25	25	25				25	25	25				25		25
H8320	005	0	1	04	01	H8320_005_0	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	25						25						25		25
H8320	006	0	1	04	01	H8320_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	0	0	0				0	0	0				0		0
H8320	006	0	1	04	01	H8320_006_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	25	25	25				25	25	25				25		25
H8320	006	0	1	04	01	H8320_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				39.00	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	21	21	21				21	21	21				21		21
H8320	006	0	1	04	01	H8320_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				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	25	25	25				25	25	25				25		25
H8320	006	0	1	04	01	H8320_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	25						25						25		25
H8320	011	0	1	04	01	H8320_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8320	011	0	1	04	01	H8320_011_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8320	011	0	1	04	01	H8320_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H8320	011	0	1	04	01	H8320_011_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H8320	011	0	1	04	01	H8320_011_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8320	011	0	1	04	01	H8320_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8320	012	0	1	04	01	H8320_012_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8320	012	0	1	04	01	H8320_012_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8320	012	0	1	04	01	H8320_012_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8320	012	0	1	04	01	H8320_012_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H8320	012	0	1	04	01	H8320_012_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8320	012	0	1	04	01	H8320_012_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8320	013	0	1	04	01	H8320_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8320	013	0	1	04	01	H8320_013_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8320	013	0	1	04	01	H8320_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H8320	013	0	1	04	01	H8320_013_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H8320	013	0	1	04	01	H8320_013_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8320	013	0	1	04	01	H8320_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8320	014	0	1	04	01	H8320_014_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8320	014	0	1	04	01	H8320_014_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8320	014	0	1	04	01	H8320_014_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H8320	014	0	1	04	01	H8320_014_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H8320	014	0	1	04	01	H8320_014_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8320	014	0	1	04	01	H8320_014_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8330	002	0	1	01	01	H8330_002_0	11		N	Single Tier	4	11	1	1	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				15.48	25	25	25																		25	25	25															25			25								Single Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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											74.09	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											42.87	25	25	25				50.20	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											582.53	25						659.79	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	25			25			25			25			25		25
H8379	001	0	1	01	01	H8379_001_0	6		N	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																														
H8379	001	0	1	01	01	H8379_001_0	6		N	Generic	4	01	1	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8379	001	0	1	01	01	H8379_001_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				67.12	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	001	0	1	01	01	H8379_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				22.12	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	001	0	1	01	01	H8379_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8379	003	1	1	01	01	H8379_003_1	6		N	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																														
H8379	003	1	1	01	01	H8379_003_1	6		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																														
H8379	003	1	1	01	01	H8379_003_1	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				65.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	1	1	01	01	H8379_003_1	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				21.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	1	1	01	01	H8379_003_1	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8379	003	2	1	01	01	H8379_003_2	6		N	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																														
H8379	003	2	1	01	01	H8379_003_2	6		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																														
H8379	003	2	1	01	01	H8379_003_2	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				65.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	2	1	01	01	H8379_003_2	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				21.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	2	1	01	01	H8379_003_2	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8379	003	3	1	01	01	H8379_003_3	6		N	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																														
H8379	003	3	1	01	01	H8379_003_3	6		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																														
H8379	003	3	1	01	01	H8379_003_3	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				65.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	3	1	01	01	H8379_003_3	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				21.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	3	1	01	01	H8379_003_3	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8379	003	4	1	01	01	H8379_003_4	6		N	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																														
H8379	003	4	1	01	01	H8379_003_4	6		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																														
H8379	003	4	1	01	01	H8379_003_4	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				65.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	4	1	01	01	H8379_003_4	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				21.25	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8379	003	4	1	01	01	H8379_003_4	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8385	001	0	1	04	01	H8385_001_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								2.00	4.00	6.00					0.00	0.00	0.00											2.00	4.00	6.00				0.00	0.00	0.00				2.00				2.00			0.06	0.00		0.06	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	6			Generic	4	01	1	2	2	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			0.29	0.12		0.29	0.12	0.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	001	0	1	04	01	H8385_001_0	6			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	001	0	1	04	01	H8385_001_0	6			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											96.35	50	50	50				96.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	001	0	1	04	01	H8385_001_0	6			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											913.84	29	29	29				880.82	29	29	29										29	29	29				29	29	29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8385	001	0	1	04	01	H8385_001_0	6			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				34	68	102	2	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	0.00				0.00				0.00			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				34	68	102	2	2				34	68	102	34		34								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			0.12	0.00		0.12	0.00	0.12	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				34	68	102	2	2				34	68	102	34		34								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			0.29	0.12		0.29	0.12	0.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	002	0	1	04	01	H8385_002_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	002	0	1	04	01	H8385_002_0	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											88.03	50	50	50				88.63	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	002	0	1	04	01	H8385_002_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											654.32	29	29	29				615.76	29	29	29										29	29	29				29	29	29			29			29								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				34	68	102	2	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	0.00				0.00				0.00			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	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			0.09	0.00		0.09	0.00	0.09	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8385	003	0	1	04	01	H8385_003_0	5			Generic	4	01	1	2	2	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			0.24	0.12		0.24	0.12	0.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	003	0	1	04	01	H8385_003_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	003	0	1	04	01	H8385_003_0	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											97.82	48	48	48				98.38	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	003	0	1	04	01	H8385_003_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											780.44	29	29	29				769.96	29	29	29										29	29	29				29	29	29			29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8385	003	0	1	04	01	H8385_003_0	5			Select Care Drugs	4	11	1	2	6	1		111	01		111	1				34	68	102	2	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	0.00				0.00				0.00			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				34	68	102	2	2				34	68	102	34		34								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			0.12	0.00		0.12	0.00	0.12	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				34	68	102	2	2				34	68	102	34		34								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			0.29	0.12		0.29	0.12	0.29	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	004	0	1	04	01	H8385_004_0	5			Preferred Brand	4	10	1	2	3	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34								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			1.38	1.24		1.38	1.24	1.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	004	0	1	04	01	H8385_004_0	5			Non-Preferred Drug	4	10	1	1	4	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											79.43	50	50	50				79.85	50	50	50										50	50	50				50	50	50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8385	004	0	1	04	01	H8385_004_0	5			Specialty Tier	4	11	1	1	5	1		111	01		111	1				34	68	102	2	2				34	68	102	34		34											715.40	29	29	29				682.55	29	29	29										29	29	29				29	29	29			29			29								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				34	68	102	2	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	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8390	017	0	1	01	01	H8390_017_0	6		N	Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	102				1	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8390	017	0	1	01	01	H8390_017_0	6		N	Generic	4	11	1	2	2	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8390	017	0	1	01	01	H8390_017_0	6		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31				62.31	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	25	25	25				25	25	25				25		25
H8390	017	0	1	01	01	H8390_017_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	102				2	2	30	60	102				30		31				40.08	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	25	25	25				25	25	25				25		25
H8390	017	0	1	01	01	H8390_017_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				430.01	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	009	0	1	01	01	H8432_009_0	4			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	01	01	H8432_009_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	009	0	1	01	01	H8432_009_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8432	009	0	1	01	01	H8432_009_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											26.00	30	30	30				17.00	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	25	25	25	25	25	25	25	25	25				25		25
H8432	009	0	1	01	01	H8432_009_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34											0.00	30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	010	0	1	01	01	H8432_010_0	4			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	01	01	H8432_010_0	4			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	01	01	H8432_010_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											78.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8432	010	0	1	01	01	H8432_010_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											35.00	30	30	30				22.00	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	25	25	25	25	25	25	25	25	25				25		25
H8432	010	0	1	01	01	H8432_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34											0.00	30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	011	0	1	01	01	H8432_011_0	4			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	01	01	H8432_011_0	4			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	011	0	1	01	01	H8432_011_0	4			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											62.00	25	25	25				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8432	011	0	1	01	01	H8432_011_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											25.00	30	30	30				15.00	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	25	25	25	25	25	25	25	25	25				25		25
H8432	011	0	1	01	01	H8432_011_0	4			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																														
H8432	016	0	1	02	01	H8432_016_0	4			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																														
H8432	016	0	1	02	01	H8432_016_0	4			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					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																														
H8432	016	0	1	02	01	H8432_016_0	4			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				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	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8432	016	0	1	02	01	H8432_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		34											15.00	30	30	30				23.00	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	25	25	25	25	25	25	25	25	25				25		25
H8432	016	0	1	02	01	H8432_016_0	4			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																														
H8432	040	0	1	02	01	H8432_040_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	040	0	1	02	01	H8432_040_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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8432	040	0	1	02	01	H8432_040_0	7			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											83.00	25	25	25				119.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H8432	040	0	1	02	01	H8432_040_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											28.00	30	30	30				21.00	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	25	25	25	25	25	25	25	25	25				25		25
H8432	040	0	1	02	01	H8432_040_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																														
H8432	041	0	1	01	01	H8432_041_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8432	041	0	1	01	01	H8432_041_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8432	041	0	1	01	01	H8432_041_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				97.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8432	041	0	1	01	01	H8432_041_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8432	041	0	1	01	01	H8432_041_0	6		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																														
H8432	041	0	1	01	01	H8432_041_0	6		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																														
H8432	042	0	1	01	01	H8432_042_0	5		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																														
H8432	042	0	1	01	01	H8432_042_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8432	042	0	1	01	01	H8432_042_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				101.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8432	042	0	1	01	01	H8432_042_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		34				45.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8432	042	0	1	01	01	H8432_042_0	5		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																														
H8432	042	0	1	01	01	H8432_042_0	5		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																														
H8481	001	0	1	04	01	H8481_001_0	6		N	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	0	0	0				0	0	0				0		0
H8481	001	0	1	04	01	H8481_001_0	6		N	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 Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8481	001	0	1	04	01	H8481_001_0	6		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				98.36	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	25	25	25				25	25	25				25		25
H8481	001	0	1	04	01	H8481_001_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				79.01	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	25	25	25				25	25	25				25		25
H8481	001	0	1	04	01	H8481_001_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				512.46	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	25	25	25				25	25	25				25		25
H8547	001	0	1	01	01	H8547_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8547	001	0	1	01	01	H8547_001_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8547	001	0	1	01	01	H8547_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											50.76	21	21	21				45.48	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	21	17	17	17	21		21
H8547	001	0	1	01	01	H8547_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											86.54	42	42	42				81.97	38	38	38										42	42	42				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8547	001	0	1	01	01	H8547_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											758.05	27						604.72	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8552	028	0	1	04	01	H8552_028_0	5			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8552	028	0	1	04	01	H8552_028_0	5			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																														
H8552	028	0	1	04	01	H8552_028_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											39.00	20	20	20				48.00	15	15	15				15	15	15															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	90.00				30.00		30.00	20	20	20	15	15	15	15	15	15				20		20
H8552	028	0	1	04	01	H8552_028_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											32.00	25	25	25				19.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
H8552	028	0	1	04	01	H8552_028_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												33							33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8552	028	0	1	04	01	H8552_028_0	5			Select Care Drugs	4	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																														
H8554	001	0	1	01	01	H8554_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8554	001	0	1	01	01	H8554_001_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8554	001	0	1	01	01	H8554_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											45.65	19	19	19				42.99	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8554	001	0	1	01	01	H8554_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											68.44	40	40	40				78.59	38	38	38										40	40	40				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8554	001	0	1	01	01	H8554_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											627.04	27						612.91	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8578	001	0	1	01	01	H8578_001_0	5			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	5			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	25	25	25	25	25	25			25			25	25		25
H8578	001	0	1	01	01	H8578_001_0	5			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	25	25	25	25	25	25			25			25	25		25
H8578	001	0	1	01	01	H8578_001_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											96.88	40	40	40				98.52	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			70.00			70.00	35.00		35.00	25	25	25	25	25	25			25			25	25		25
H8578	001	0	1	01	01	H8578_001_0	5			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	29						1.00	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00									35.00		35.00	25			25									25		25
H8578	004	0	1	01	01	H8578_004_0	5			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	5			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	25	25	25	25	25	25			25			25	25		25
H8578	004	0	1	01	01	H8578_004_0	5			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	25	25	25	25	25	25			25			25	25		25
H8578	004	0	1	01	01	H8578_004_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											98.65	36	36	36				94.37	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	25	25	25	25	25	25			25			25	25		25
H8578	004	0	1	01	01	H8578_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31											1.00	29						1.00	29																							29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00									35.00		35.00	25			25									25		25
H8578	012	0	1	01	01	H8578_012_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																														
H8578	012	0	1	01	01	H8578_012_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	25	25	25	25	25	25			25			25	25		25
H8578	012	0	1	01	01	H8578_012_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	25	25	25	25	25	25			25			25	25		25
H8578	012	0	1	01	01	H8578_012_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		100	1				30	60	90	1	2						90	30		31											86.38	33	33	33				98.60	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			70.00			70.00	35.00		35.00	25	25	25	25	25	25			25			25	25		25
H8578	012	0	1	01	01	H8578_012_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	25			25									25		25
H8597	001	0	1	01	01	H8597_001_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	001	0	1	01	01	H8597_001_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	001	0	1	01	01	H8597_001_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				86.44	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	22	22	22				22	22	22				22		22
H8597	001	0	1	01	01	H8597_001_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				39.62	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	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8597	001	0	1	01	01	H8597_001_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				494.21	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8597	002	0	1	01	01	H8597_002_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	002	0	1	01	01	H8597_002_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	002	0	1	01	01	H8597_002_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				73.89	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	22	22	22				22	22	22				22		22
H8597	002	0	1	01	01	H8597_002_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				37.34	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	25	25	25				25	25	25				25		25
H8597	002	0	1	01	01	H8597_002_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				500.34	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8597	003	0	1	01	01	H8597_003_0	3		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	003	0	1	01	01	H8597_003_0	3		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8597	003	0	1	01	01	H8597_003_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				79.38	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	22	22	22				22	22	22				22		22
H8597	003	0	1	01	01	H8597_003_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				41.14	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8597	003	0	1	01	01	H8597_003_0	3		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				495.95	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8604	011	0	1	04	01	H8604_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								13.00	26.00	39.00					3.00	6.00	9.00											13.00	26.00	39.00				3.00	6.00	9.00				13.00				13.00			0.43	0.10		0.43	0.10	0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8604	011	0	1	04	01	H8604_011_0	5			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00											20.00	40.00	60.00				10.00	20.00	30.00				20.00				20.00			0.67	0.33		0.67	0.33	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8604	011	0	1	04	01	H8604_011_0	5			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	011	0	1	04	01	H8604_011_0	5			Non-Preferred Drug	4	11	1	2	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								100.00	200.00	300.00					100.00	200.00	300.00											100.00	200.00	300.00				100.00	200.00	300.00				100.00				100.00			3.33	3.33		3.33	3.33	3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	011	0	1	04	01	H8604_011_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																														
H8604	014	1	1	04	01	H8604_014_1	5			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	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					2.00	4.00	6.00											20.00	40.00	60.00				2.00	4.00	6.00				20.00				20.00			0.67	0.07		0.67	0.07	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8604	014	1	1	04	01	H8604_014_1	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.33	25	25	25				58.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	014	1	1	04	01	H8604_014_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											34.55	40	40	40				29.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	014	1	1	04	01	H8604_014_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																														
H8604	014	2	1	04	01	H8604_014_2	5			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	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					2.00	4.00	6.00											20.00	40.00	60.00				2.00	4.00	6.00				20.00				20.00			0.67	0.07		0.67	0.07	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8604	014	2	1	04	01	H8604_014_2	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											58.33	25	25	25				58.90	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	014	2	1	04	01	H8604_014_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											34.55	40	40	40				29.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	014	2	1	04	01	H8604_014_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																														
H8604	015	0	1	04	01	H8604_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								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	015	0	1	04	01	H8604_015_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					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																														
H8604	015	0	1	04	01	H8604_015_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											46.37	20	20	20				46.45	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H8604	015	0	1	04	01	H8604_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											42.82	40	40	40				28.63	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8604	015	0	1	04	01	H8604_015_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												31							31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	003	0	1	04	01	H8634_003_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	003	0	1	04	01	H8634_003_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	003	0	1	04	01	H8634_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											49.84	20	20	20				43.34	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8634	003	0	1	04	01	H8634_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											76.64	39	39	39				85.45	37	37	37										39	39	39				37	37	37			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	003	0	1	04	01	H8634_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											630.12	27						633.08	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	004	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	004	0	1	04	01	H8634_004_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	004	0	1	04	01	H8634_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											51.41	21	21	21				43.92	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	18	18	18	21	21	21	18	18	18	21		21
H8634	004	0	1	04	01	H8634_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											87.58	46	46	46				88.00	42	42	42										46	46	46				42	42	42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	004	0	1	04	01	H8634_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											656.09	29						525.56	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	008	0	1	04	01	H8634_008_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	008	0	1	04	01	H8634_008_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	008	0	1	04	01	H8634_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											42.78	19	19	19				35.51	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	008	0	1	04	01	H8634_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											74.52	39	39	39				82.31	36	36	36										39	39	39				36	36	36			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	008	0	1	04	01	H8634_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											561.70	25						692.72	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	010	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	010	0	1	04	01	H8634_010_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	010	0	1	04	01	H8634_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											52.03	19	19	19				45.08	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	010	0	1	04	01	H8634_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											74.24	39	39	39				70.34	37	37	37										39	39	39				37	37	37			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	010	0	1	04	01	H8634_010_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											624.01	25						568.38	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	012	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	012	0	1	04	01	H8634_012_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	012	0	1	04	01	H8634_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											51.19	19	19	19				45.81	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	012	0	1	04	01	H8634_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											73.69	42	42	42				81.11	39	39	39										42	42	42				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	012	0	1	04	01	H8634_012_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.30	27						628.53	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	018	0	1	04	01	H8634_018_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	018	0	1	04	01	H8634_018_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	018	0	1	04	01	H8634_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											38.85	20	20	20				34.49	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8634	018	0	1	04	01	H8634_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											64.99	38	38	38				74.98	36	36	36										38	38	38				36	36	36			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	018	0	1	04	01	H8634_018_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											526.25	25						587.55	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	021	0	1	04	01	H8634_021_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	021	0	1	04	01	H8634_021_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	021	0	1	04	01	H8634_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											42.81	21	21	21				36.11	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	21	17	17	17	21		21
H8634	021	0	1	04	01	H8634_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											74.25	35	35	35				73.30	32	32	32										35	35	35				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	021	0	1	04	01	H8634_021_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											640.01	25						623.21	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	022	0	1	04	01	H8634_022_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	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	022	0	1	04	01	H8634_022_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	022	0	1	04	01	H8634_022_0	9			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											41.75	20	20	20				43.00	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8634	022	0	1	04	01	H8634_022_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											84.01	43	43	43				92.78	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	022	0	1	04	01	H8634_022_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											721.18	27						673.91	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	023	0	1	04	01	H8634_023_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	023	0	1	04	01	H8634_023_0	9			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	023	0	1	04	01	H8634_023_0	9			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											43.92	20	20	20				44.36	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H8634	023	0	1	04	01	H8634_023_0	9			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											95.36	44	44	44				85.92	40	40	40										44	44	44				40	40	40			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	023	0	1	04	01	H8634_023_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											807.77	27						636.62	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	024	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	024	0	1	04	01	H8634_024_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	024	0	1	04	01	H8634_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											42.60	20	20	20				40.52	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8634	024	0	1	04	01	H8634_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											83.08	40	40	40				82.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	024	0	1	04	01	H8634_024_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											660.80	25						597.45	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	025	0	1	04	01	H8634_025_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	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	025	0	1	04	01	H8634_025_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	025	0	1	04	01	H8634_025_0	8			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											45.92	20	20	20				43.89	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H8634	025	0	1	04	01	H8634_025_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											80.74	42	42	42				83.65	39	39	39										42	42	42				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	025	0	1	04	01	H8634_025_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											779.15	25						571.16	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	027	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	027	0	1	04	01	H8634_027_0	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								6.00	12.00	18.00					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	027	0	1	04	01	H8634_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											51.21	19	19	19				47.60	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	027	0	1	04	01	H8634_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											63.69	39	39	39				68.88	36	36	36										39	39	39				36	36	36			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	027	0	1	04	01	H8634_027_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											582.46	25						572.31	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	029	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	029	0	1	04	01	H8634_029_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	029	0	1	04	01	H8634_029_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											39.41	19	19	19				31.92	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	029	0	1	04	01	H8634_029_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											67.60	37	37	37				78.78	34	34	34										37	37	37				34	34	34			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	029	0	1	04	01	H8634_029_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											531.32	25						562.40	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	030	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	030	0	1	04	01	H8634_030_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	030	0	1	04	01	H8634_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											35.49	20	20	20				30.42	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H8634	030	0	1	04	01	H8634_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											62.87	36	36	36				71.28	33	33	33										36	36	36				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	030	0	1	04	01	H8634_030_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											515.68	25						512.87	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	031	0	1	04	01	H8634_031_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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	031	0	1	04	01	H8634_031_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	031	0	1	04	01	H8634_031_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											47.67	19	19	19				45.45	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	70.00	35.00	70.00	70.00	35.00		35.00	19	19	19	17	17	17	19	19	19	17	17	17	19		19
H8634	031	0	1	04	01	H8634_031_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											74.43	40	40	40				79.66	38	38	38										40	40	40				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	031	0	1	04	01	H8634_031_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											624.00	27						600.69	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	032	0	1	04	01	H8634_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	032	0	1	04	01	H8634_032_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	032	0	1	04	01	H8634_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											47.23	20	20	20				45.69	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	18	18	18	20	20	20	18	18	18	20		20
H8634	032	0	1	04	01	H8634_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											73.43	43	43	43				78.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	032	0	1	04	01	H8634_032_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.79	29						618.39	29												29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8634	033	0	1	04	01	H8634_033_0	7			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	033	0	1	04	01	H8634_033_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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	033	0	1	04	01	H8634_033_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31											49.78	21	21	21				45.77	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	19	17	17	17	21		21
H8634	033	0	1	04	01	H8634_033_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											74.17	40	40	40				76.15	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8634	033	0	1	04	01	H8634_033_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											619.33	27						606.72	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8649	010	0	1	01	01	H8649_010_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8649	010	0	1	01	01	H8649_010_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31	10.00	20.00	30.00																			10.00	20.00	30.00																	10.00			10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8649	010	0	1	01	01	H8649_010_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				72.90	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	22	22	22				22	22	22				22		22
H8649	010	0	1	01	01	H8649_010_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				38.72	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		35.00	25	25	25				25	25	25				25		25
H8649	010	0	1	01	01	H8649_010_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				506.37	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8649	013	0	1	01	01	H8649_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																														
H8649	013	0	1	01	01	H8649_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																														
H8649	013	0	1	01	01	H8649_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											67.49	24	24	24				94.77	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H8649	013	0	1	01	01	H8649_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											41.70	25	25	25				48.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8649	013	0	1	01	01	H8649_013_0	2			Specialty Tier	4	11	1	1	5	1		010	10		010	1				30								30				10	31											578.15	25						720.40	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	25			25			25			25			25		25
H8764	001	0	1	01	01	H8764_001_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	4.00	8.00	12.00																					8.00																4.00				4.00		0.13						0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	4.00	8.00	12.00						8.00				4.00		4.00	25	25	25						25				25		25
H8764	001	0	1	01	01	H8764_001_0	5			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	15.00	30.00	45.00																					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	45.00						30.00				15.00		15.00	25	25	25						25				25		25
H8764	001	0	1	01	01	H8764_001_0	5			Preferred Brand	4	10	1	2	3	1	111		01	100		1	30	60	90				1	2			90				30		31	47.00	94.00	141.00																					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	105.00						94.00				35.00		35.00	25	25	25						25				25		25
H8764	001	0	1	01	01	H8764_001_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				29.83	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	001	0	1	01	01	H8764_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				277.58	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	001	0	1	01	01	H8764_001_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				1	2			90				30		31	11.00	22.00	33.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	11.00	22.00	33.00						22.00				11.00		11.00	25	25	25						25				25		25
H8764	002	0	1	02	01	H8764_002_0	5			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	0.00	0.00	0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00						0.00				0.00		0.00	0	0	0						0				0		0
H8764	002	0	1	02	01	H8764_002_0	5			Generic	4	01	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, Select Care Drugs	10.00	20.00	30.00						20.00				10.00		10.00	25	25	25						25				25		25
H8764	002	0	1	02	01	H8764_002_0	5			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																					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	105.00						90.00				35.00		35.00	25	25	25						25				25		25
H8764	002	0	1	02	01	H8764_002_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				28.53	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	002	0	1	02	01	H8764_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				398.13	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	002	0	1	02	01	H8764_002_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				1	2			90				30		31	11.00	22.00	33.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	11.00	22.00	33.00						22.00				11.00		11.00	25	25	25						25				25		25
H8764	003	0	1	01	01	H8764_003_0	6			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	9.00	18.00	27.00																					18.00																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						18.00				9.00		9.00	25	25	25						25				25		25
H8764	003	0	1	01	01	H8764_003_0	6			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	20.00	40.00	60.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00						40.00				20.00		20.00	25	25	25						25				25		25
H8764	003	0	1	01	01	H8764_003_0	6			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																					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	105.00						94.00				35.00		35.00	25	25	25						25				25		25
H8764	003	0	1	01	01	H8764_003_0	6			Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				31.94	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	003	0	1	01	01	H8764_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31				340.96	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	003	0	1	01	01	H8764_003_0	6			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				1	2			90				30		31	11.00	22.00	33.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	11.00	22.00	33.00						22.00				11.00		11.00	25	25	25						25				25		25
H8764	004	0	1	01	01	H8764_004_0	7			Preferred Generic	4	01	1	2	1	1	111		01	100		1	30	60	90				1	2			90				30		31	9.00	18.00	27.00																					18.00																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						18.00				9.00		9.00	25	25	25						25				25		25
H8764	004	0	1	01	01	H8764_004_0	7			Generic	4	01	1	2	2	1	111		01	100		1	30	60	90				1	2			90				30		31	20.00	40.00	60.00																					40.00																20.00				20.00		0.67						0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00						40.00				20.00		20.00	25	25	25						25				25		25
H8764	004	0	1	01	01	H8764_004_0	7			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																					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	105.00						94.00				35.00		35.00	25	25	25						25				25		25
H8764	004	0	1	01	01	H8764_004_0	7			Non-Preferred Drug	4	11	1	1	4	1	010		01	000		1	30														30		31				27.74	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
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				429.68	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00												35.00		35.00	25												25		25
H8764	004	0	1	01	01	H8764_004_0	7			Select Care Drugs	4	11	1	2	6	1	111		01	100		1	30	60	90				1	2			90				30		31	11.00	22.00	33.00																					22.00																11.00				11.00		0.37						0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	11.00	22.00	33.00						22.00				11.00		11.00	25	25	25						25				25		25
H8768	005	0	1	04	01	H8768_005_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	005	0	1	04	01	H8768_005_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	005	0	1	04	01	H8768_005_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	005	0	1	04	01	H8768_005_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				92.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	005	0	1	04	01	H8768_005_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
H8768	007	0	1	04	01	H8768_007_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	007	0	1	04	01	H8768_007_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	007	0	1	04	01	H8768_007_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	007	0	1	04	01	H8768_007_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	007	0	1	04	01	H8768_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
H8768	008	0	1	04	01	H8768_008_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	008	0	1	04	01	H8768_008_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	008	0	1	04	01	H8768_008_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	008	0	1	04	01	H8768_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	008	0	1	04	01	H8768_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				348.00	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	25						25			25			25		25
H8768	009	0	1	04	01	H8768_009_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	009	0	1	04	01	H8768_009_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	009	0	1	04	01	H8768_009_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				45.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H8768	009	0	1	04	01	H8768_009_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	009	0	1	04	01	H8768_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				362.00	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	25						25			25			25		25
H8768	010	0	1	04	01	H8768_010_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	010	0	1	04	01	H8768_010_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	010	0	1	04	01	H8768_010_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	010	0	1	04	01	H8768_010_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	010	0	1	04	01	H8768_010_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				372.00	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	25						25			25			25		25
H8768	011	0	1	04	01	H8768_011_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	011	0	1	04	01	H8768_011_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	011	0	1	04	01	H8768_011_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	011	0	1	04	01	H8768_011_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				61.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	011	0	1	04	01	H8768_011_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				368.00	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	25						25			25			25		25
H8768	013	0	1	04	01	H8768_013_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	013	0	1	04	01	H8768_013_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	013	0	1	04	01	H8768_013_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	013	0	1	04	01	H8768_013_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				65.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	013	0	1	04	01	H8768_013_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				302.00	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	25						25			25			25		25
H8768	016	0	1	04	01	H8768_016_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	016	0	1	04	01	H8768_016_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	016	0	1	04	01	H8768_016_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	016	0	1	04	01	H8768_016_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	016	0	1	04	01	H8768_016_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H8768	017	1	1	04	01	H8768_017_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	017	1	1	04	01	H8768_017_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	017	1	1	04	01	H8768_017_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	017	1	1	04	01	H8768_017_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	017	1	1	04	01	H8768_017_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				337.00	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	25						25			25			25		25
H8768	017	2	1	04	01	H8768_017_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	017	2	1	04	01	H8768_017_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	017	2	1	04	01	H8768_017_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	017	2	1	04	01	H8768_017_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	42																										42						42					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	017	2	1	04	01	H8768_017_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				337.00	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	25						25			25			25		25
H8768	022	0	1	04	01	H8768_022_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	022	0	1	04	01	H8768_022_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	022	0	1	04	01	H8768_022_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	022	0	1	04	01	H8768_022_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				89.00	38																										38						38					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	022	0	1	04	01	H8768_022_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H8768	023	0	1	04	01	H8768_023_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	023	0	1	04	01	H8768_023_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	8.00		24.00																											24.00						0.00				8.00				8.00		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	023	0	1	04	01	H8768_023_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				43.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H8768	023	0	1	04	01	H8768_023_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				81.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	023	0	1	04	01	H8768_023_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				370.00	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	25						25			25			25		25
H8768	024	0	1	04	01	H8768_024_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	024	0	1	04	01	H8768_024_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	024	0	1	04	01	H8768_024_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	024	0	1	04	01	H8768_024_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				71.00	40																										40						40					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	024	0	1	04	01	H8768_024_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				402.00	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	25						25			25			25		25
H8768	026	0	1	04	01	H8768_026_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	026	0	1	04	01	H8768_026_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	026	0	1	04	01	H8768_026_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	026	0	1	04	01	H8768_026_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				80.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	026	0	1	04	01	H8768_026_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				357.00	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	25						25			25			25		25
H8768	027	0	1	04	01	H8768_027_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	027	0	1	04	01	H8768_027_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	027	0	1	04	01	H8768_027_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				40.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	027	0	1	04	01	H8768_027_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				75.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	027	0	1	04	01	H8768_027_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				334.00	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	25						25			25			25		25
H8768	030	0	1	04	01	H8768_030_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	030	0	1	04	01	H8768_030_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	030	0	1	04	01	H8768_030_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	030	0	1	04	01	H8768_030_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	41																										41						41					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	030	0	1	04	01	H8768_030_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				354.00	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	25						25			25			25		25
H8768	034	0	1	04	01	H8768_034_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	034	0	1	04	01	H8768_034_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	034	0	1	04	01	H8768_034_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	034	0	1	04	01	H8768_034_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				66.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	034	0	1	04	01	H8768_034_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H8768	035	0	1	04	01	H8768_035_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	035	0	1	04	01	H8768_035_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	035	0	1	04	01	H8768_035_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	035	0	1	04	01	H8768_035_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				73.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	035	0	1	04	01	H8768_035_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				359.00	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	25						25			25			25		25
H8768	037	1	1	04	01	H8768_037_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	037	1	1	04	01	H8768_037_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	037	1	1	04	01	H8768_037_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	037	1	1	04	01	H8768_037_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	037	1	1	04	01	H8768_037_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				344.00	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	25						25			25			25		25
H8768	037	2	1	04	01	H8768_037_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	037	2	1	04	01	H8768_037_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	037	2	1	04	01	H8768_037_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				36.00	15		15																										15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	15		15						15			15	15		15
H8768	037	2	1	04	01	H8768_037_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				67.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	037	2	1	04	01	H8768_037_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				344.00	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	25						25			25			25		25
H8768	039	0	1	04	01	H8768_039_0	5			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	039	0	1	04	01	H8768_039_0	5			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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	039	0	1	04	01	H8768_039_0	5			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				47.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
H8768	039	0	1	04	01	H8768_039_0	5			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				83.00	39																										39						39					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	039	0	1	04	01	H8768_039_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				344.00	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	25						25			25			25		25
H8768	040	0	1	04	01	H8768_040_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	040	0	1	04	01	H8768_040_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	040	0	1	04	01	H8768_040_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				46.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
H8768	040	0	1	04	01	H8768_040_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	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	25						25			25			25		25
H8768	040	0	1	04	01	H8768_040_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H8768	046	0	1	04	01	H8768_046_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	046	0	1	04	01	H8768_046_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	10.00		30.00																											30.00						0.00				10.00				10.00		0.33						0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	046	0	1	04	01	H8768_046_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				39.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	046	0	1	04	01	H8768_046_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				79.00	37																										37						37					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	046	0	1	04	01	H8768_046_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				385.00	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	25						25			25			25		25
H8768	055	1	1	04	01	H8768_055_1	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	055	1	1	04	01	H8768_055_1	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	055	1	1	04	01	H8768_055_1	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	055	1	1	04	01	H8768_055_1	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	055	1	1	04	01	H8768_055_1	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H8768	055	2	1	04	01	H8768_055_2	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	055	2	1	04	01	H8768_055_2	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	055	2	1	04	01	H8768_055_2	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	055	2	1	04	01	H8768_055_2	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	055	2	1	04	01	H8768_055_2	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				363.00	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	25						25			25			25		25
H8768	058	0	1	04	01	H8768_058_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	058	0	1	04	01	H8768_058_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	058	0	1	04	01	H8768_058_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				41.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	058	0	1	04	01	H8768_058_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				88.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	058	0	1	04	01	H8768_058_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				383.00	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	25						25			25			25		25
H8768	061	0	1	04	01	H8768_061_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	061	0	1	04	01	H8768_061_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	061	0	1	04	01	H8768_061_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				35.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	061	0	1	04	01	H8768_061_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	061	0	1	04	01	H8768_061_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				389.00	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	25						25			25			25		25
H8768	062	0	1	04	01	H8768_062_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	062	0	1	04	01	H8768_062_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	062	0	1	04	01	H8768_062_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	062	0	1	04	01	H8768_062_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	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	25						25			25			25		25
H8768	062	0	1	04	01	H8768_062_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				381.00	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	25						25			25			25		25
H8768	063	0	1	04	01	H8768_063_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	063	0	1	04	01	H8768_063_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	12.00		36.00																											36.00						0.00				12.00				12.00		0.40						0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8768	063	0	1	04	01	H8768_063_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				38.00	16		16																										16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	16		16						16			16	16		16
H8768	063	0	1	04	01	H8768_063_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				72.00	43																										43						43					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
H8768	063	0	1	04	01	H8768_063_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				360.00	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	25						25			25			25		25
H8794	001	0	1	01	01	H8794_001_0	5		N	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	0	0	0				0	0	0				0		0
H8794	001	0	1	01	01	H8794_001_0	5		N	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	0	0	0				0	0	0				0		0
H8794	001	0	1	01	01	H8794_001_0	5		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	001	0	1	01	01	H8794_001_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				42.00	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	0	0	0				0	0	0				0		0
H8794	001	0	1	01	01	H8794_001_0	5		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	0	0	0				0	0	0				0		0
H8794	001	0	1	01	01	H8794_001_0	5		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	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	0	0	0				0	0	0				0		0
H8794	002	0	1	01	01	H8794_002_0	7		N	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	0	0	0				0	0	0				0		0
H8794	002	0	1	01	01	H8794_002_0	7		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
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				47.00	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	0	0	0				0	0	0				0		0
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	0	0	0				0	0	0				0		0
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	006	0	1	01	01	H8794_006_0	6		N	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	0	0	0				0	0	0				0		0
H8794	006	0	1	01	01	H8794_006_0	6		N	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	0	0	0				0	0	0				0		0
H8794	006	0	1	01	01	H8794_006_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	006	0	1	01	01	H8794_006_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				45.00	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	0	0	0				0	0	0				0		0
H8794	006	0	1	01	01	H8794_006_0	6		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	0	0	0				0	0	0				0		0
H8794	006	0	1	01	01	H8794_006_0	6		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	007	0	1	01	01	H8794_007_0	5		N	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	0	0	0				0	0	0				0		0
H8794	007	0	1	01	01	H8794_007_0	5		N	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	0	0	0				0	0	0				0		0
H8794	007	0	1	01	01	H8794_007_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				14.00	5	5	5																		0	0	0															5			5								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	0	0	0				0	0	0				0		0
H8794	007	0	1	01	01	H8794_007_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8794	007	0	1	01	01	H8794_007_0	5		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	0	0	0				0	0	0				0		0
H8794	007	0	1	01	01	H8794_007_0	5		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	009	0	1	01	01	H8794_009_0	6		N	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	0	0	0				0	0	0				0		0
H8794	009	0	1	01	01	H8794_009_0	6		N	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	0	0	0				0	0	0				0		0
H8794	009	0	1	01	01	H8794_009_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	009	0	1	01	01	H8794_009_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				42.00	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	0	0	0				0	0	0				0		0
H8794	009	0	1	01	01	H8794_009_0	6		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	0	0	0				0	0	0				0		0
H8794	009	0	1	01	01	H8794_009_0	6		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	010	0	1	01	01	H8794_010_0	6		N	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	0	0	0				0	0	0				0		0
H8794	010	0	1	01	01	H8794_010_0	6		N	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	0	0	0				0	0	0				0		0
H8794	010	0	1	01	01	H8794_010_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	010	0	1	01	01	H8794_010_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				42.00	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	0	0	0				0	0	0				0		0
H8794	010	0	1	01	01	H8794_010_0	6		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	0	0	0				0	0	0				0		0
H8794	010	0	1	01	01	H8794_010_0	6		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	011	0	1	01	01	H8794_011_0	7		N	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	0	0	0				0	0	0				0		0
H8794	011	0	1	01	01	H8794_011_0	7		N	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	0	0	0				0	0	0				0		0
H8794	011	0	1	01	01	H8794_011_0	7		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	011	0	1	01	01	H8794_011_0	7		N	Non-Preferred Drug	4	11	1	2	4	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	0	0	0				0	0	0				0		0
H8794	011	0	1	01	01	H8794_011_0	7		N	Specialty Tier	4	11	1	2	5	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	0	0	0				0	0	0				0		0
H8794	011	0	1	01	01	H8794_011_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	016	0	1	01	01	H8794_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		31	0.00	0.00	0.00																			0.00	0.00	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	0	0	0				0	0	0				0		0
H8794	016	0	1	01	01	H8794_016_0	6		N	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	0	0	0				0	0	0				0		0
H8794	016	0	1	01	01	H8794_016_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	016	0	1	01	01	H8794_016_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				46.00	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	0	0	0				0	0	0				0		0
H8794	016	0	1	01	01	H8794_016_0	6		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	0	0	0				0	0	0				0		0
H8794	016	0	1	01	01	H8794_016_0	6		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	017	0	1	01	01	H8794_017_0	5		N	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	0	0	0				0	0	0				0		0
H8794	017	0	1	01	01	H8794_017_0	5		N	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	0	0	0				0	0	0				0		0
H8794	017	0	1	01	01	H8794_017_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				49.00	20	20	20																		0	0	0															20			20								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	0	0	0				0	0	0				0		0
H8794	017	0	1	01	01	H8794_017_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				66.00	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	0	0	0				0	0	0				0		0
H8794	017	0	1	01	01	H8794_017_0	5		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	0	0	0				0	0	0				0		0
H8794	017	0	1	01	01	H8794_017_0	5		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	018	0	1	01	01	H8794_018_0	5		N	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	0	0	0				0	0	0				0		0
H8794	018	0	1	01	01	H8794_018_0	5		N	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	0	0	0				0	0	0				0		0
H8794	018	0	1	01	01	H8794_018_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				25.00	10	10	10																		10	10	10															10			10								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	0	0	0				0	0	0				0		0
H8794	018	0	1	01	01	H8794_018_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				66.00	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	0	0	0				0	0	0				0		0
H8794	018	0	1	01	01	H8794_018_0	5		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	0	0	0				0	0	0				0		0
H8794	018	0	1	01	01	H8794_018_0	5		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	019	0	1	01	01	H8794_019_0	5		N	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	0	0	0				0	0	0				0		0
H8794	019	0	1	01	01	H8794_019_0	5		N	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	0	0	0				0	0	0				0		0
H8794	019	0	1	01	01	H8794_019_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				2	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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8794	019	0	1	01	01	H8794_019_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H8794	019	0	1	01	01	H8794_019_0	5		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	0	0	0				0	0	0				0		0
H8794	019	0	1	01	01	H8794_019_0	5		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	020	0	1	01	01	H8794_020_0	6		N	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	0	0	0				0	0	0				0		0
H8794	020	0	1	01	01	H8794_020_0	6		N	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	0	0	0				0	0	0				0		0
H8794	020	0	1	01	01	H8794_020_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	020	0	1	01	01	H8794_020_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				52.00	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	0	0	0				0	0	0				0		0
H8794	020	0	1	01	01	H8794_020_0	6		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	0	0	0				0	0	0				0		0
H8794	020	0	1	01	01	H8794_020_0	6		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	021	0	1	01	01	H8794_021_0	6		N	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	0	0	0				0	0	0				0		0
H8794	021	0	1	01	01	H8794_021_0	6		N	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	0	0	0				0	0	0				0		0
H8794	021	0	1	01	01	H8794_021_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	021	0	1	01	01	H8794_021_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				48.00	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	0	0	0				0	0	0				0		0
H8794	021	0	1	01	01	H8794_021_0	6		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	0	0	0				0	0	0				0		0
H8794	021	0	1	01	01	H8794_021_0	6		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	022	0	1	01	01	H8794_022_0	6		N	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	0	0	0				0	0	0				0		0
H8794	022	0	1	01	01	H8794_022_0	6		N	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	0	0	0				0	0	0				0		0
H8794	022	0	1	01	01	H8794_022_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	022	0	1	01	01	H8794_022_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				47.00	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	0	0	0				0	0	0				0		0
H8794	022	0	1	01	01	H8794_022_0	6		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	0	0	0				0	0	0				0		0
H8794	022	0	1	01	01	H8794_022_0	6		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	023	0	1	01	01	H8794_023_0	6		N	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	0	0	0				0	0	0				0		0
H8794	023	0	1	01	01	H8794_023_0	6		N	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	0	0	0				0	0	0				0		0
H8794	023	0	1	01	01	H8794_023_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	023	0	1	01	01	H8794_023_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				47.00	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	0	0	0				0	0	0				0		0
H8794	023	0	1	01	01	H8794_023_0	6		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	0	0	0				0	0	0				0		0
H8794	023	0	1	01	01	H8794_023_0	6		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	024	0	1	01	01	H8794_024_0	6		N	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	0	0	0				0	0	0				0		0
H8794	024	0	1	01	01	H8794_024_0	6		N	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	0	0	0				0	0	0				0		0
H8794	024	0	1	01	01	H8794_024_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	024	0	1	01	01	H8794_024_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				48.00	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	0	0	0				0	0	0				0		0
H8794	024	0	1	01	01	H8794_024_0	6		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	0	0	0				0	0	0				0		0
H8794	024	0	1	01	01	H8794_024_0	6		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	025	0	1	01	01	H8794_025_0	6		N	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	0	0	0				0	0	0				0		0
H8794	025	0	1	01	01	H8794_025_0	6		N	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	0	0	0				0	0	0				0		0
H8794	025	0	1	01	01	H8794_025_0	6		N	Preferred Brand	4	11	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	0	0	0				0	0	0				0		0
H8794	025	0	1	01	01	H8794_025_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31				69.00	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	0	0	0				0	0	0				0		0
H8794	025	0	1	01	01	H8794_025_0	6		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	0	0	0				0	0	0				0		0
H8794	025	0	1	01	01	H8794_025_0	6		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 Drug, 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 Drug, 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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8797	003	0	1	02	01	H8797_003_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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 Drug, 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 Drug, 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 Drug, 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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8797	004	0	1	02	01	H8797_004_0	6			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				1131.00	33																				33																		33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8832	001	0	1	04	01	H8832_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H8832	001	0	1	04	01	H8832_001_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			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	25	25	25				25	25	25				25		25
H8832	001	0	1	04	01	H8832_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	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	25	25	25				25	25	25				25		25
H8832	001	0	1	04	01	H8832_001_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.75	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		35.00	25	25	25				25	25	25				25		25
H8832	001	0	1	04	01	H8832_001_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				731.41	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	7			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	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	25	25	25				25	25	25				25		25
H8832	002	0	1	04	01	H8832_002_0	7			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	25	25	25				25	25	25				25		25
H8832	002	0	1	04	01	H8832_002_0	7			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	25	25	25				25	25	25				25		25
H8832	002	0	1	04	01	H8832_002_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				58.81	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		35.00	25	25	25				25	25	25				25		25
H8832	002	0	1	04	01	H8832_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				722.33	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	7			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																														
H8832	003	0	1	04	01	H8832_003_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H8832	003	0	1	04	01	H8832_003_0	6			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				3.40	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8832	003	0	1	04	01	H8832_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				71.54	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8832	003	0	1	04	01	H8832_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				54.76	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		35.00	25	25	25				25	25	25				25		25
H8832	003	0	1	04	01	H8832_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				531.87	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8832	003	0	1	04	01	H8832_003_0	6			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	001	0	1	01	01	H8845_001_0	8		N	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																														
H8845	001	0	1	01	01	H8845_001_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.74	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	001	0	1	01	01	H8845_001_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				34.29	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	20	20	20				20	20	20				20		20
H8845	001	0	1	01	01	H8845_001_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				64.11	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		35.00	25	25	25				25	25	25				25		25
H8845	001	0	1	01	01	H8845_001_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				514.73	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	25						25						25		25
H8845	001	0	1	01	01	H8845_001_0	8		N	Select Care Drugs	4	01	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																														
H8845	004	0	1	01	01	H8845_004_0	9		N	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																														
H8845	004	0	1	01	01	H8845_004_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.69	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	004	0	1	01	01	H8845_004_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.15	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	20	20	20				20	20	20				20		20
H8845	004	0	1	01	01	H8845_004_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				69.65	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		35.00	25	25	25				25	25	25				25		25
H8845	004	0	1	01	01	H8845_004_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				680.71	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	25						25						25		25
H8845	004	0	1	01	01	H8845_004_0	9		N	Select Care Drugs	4	01	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																														
H8845	005	0	1	01	01	H8845_005_0	9		N	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																														
H8845	005	0	1	01	01	H8845_005_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.71	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	005	0	1	01	01	H8845_005_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.65	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		35.00	20	20	20				20	20	20				20		20
H8845	005	0	1	01	01	H8845_005_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				70.20	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		35.00	25	25	25				25	25	25				25		25
H8845	005	0	1	01	01	H8845_005_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				681.90	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	25						25						25		25
H8845	005	0	1	01	01	H8845_005_0	9		N	Select Care Drugs	4	01	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																														
H8845	007	1	1	01	01	H8845_007_1	9		N	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																														
H8845	007	1	1	01	01	H8845_007_1	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.71	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	007	1	1	01	01	H8845_007_1	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.50	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		35.00	20	20	20				20	20	20				20		20
H8845	007	1	1	01	01	H8845_007_1	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.75	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		35.00	25	25	25				25	25	25				25		25
H8845	007	1	1	01	01	H8845_007_1	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				484.36	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	25						25						25		25
H8845	007	1	1	01	01	H8845_007_1	9		N	Select Care Drugs	4	01	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																														
H8845	007	2	1	01	01	H8845_007_2	9		N	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																														
H8845	007	2	1	01	01	H8845_007_2	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.71	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8845	007	2	1	01	01	H8845_007_2	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				33.50	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		35.00	20	20	20				20	20	20				20		20
H8845	007	2	1	01	01	H8845_007_2	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				62.75	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		35.00	25	25	25				25	25	25				25		25
H8845	007	2	1	01	01	H8845_007_2	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				484.36	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	25						25						25		25
H8845	007	2	1	01	01	H8845_007_2	9		N	Select Care Drugs	4	01	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																														
H8849	001	0	1	02	01	H8849_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																														
H8849	001	0	1	02	01	H8849_001_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																														
H8849	001	0	1	02	01	H8849_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											61.00	20	20	20				83.00	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H8849	001	0	1	02	01	H8849_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											27.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H8849	001	0	1	02	01	H8849_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																														
H8849	001	0	1	02	01	H8849_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	0	0	0	0	0	0	0	0	0				0		0
H8849	003	0	1	02	01	H8849_003_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																														
H8849	003	0	1	02	01	H8849_003_0	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	003	0	1	02	01	H8849_003_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											84.00	25	25	25				88.00	20	20	20				20	20	20															25			25								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	25	25	25	20	20	20	20	20	20				25		25
H8849	003	0	1	02	01	H8849_003_0	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											52.00	30	30	30				24.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H8849	003	0	1	02	01	H8849_003_0	5			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																														
H8849	003	0	1	02	01	H8849_003_0	5			Select Care Drugs	4	11	1	2	6	1		111	01	111		1				30	60	100	1	2	30	60	100				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0	0	0	0	0	0	0				0		0
H8849	005	0	1	02	01	H8849_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								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	005	0	1	02	01	H8849_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											93.00	25	25	25				94.00	20	20	20				20	20	20															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	20	20	20	20	20	20				25		25
H8849	005	0	1	02	01	H8849_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											58.00	30	30	30				30.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H8849	005	0	1	02	01	H8849_005_0	5			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																														
H8849	005	0	1	02	01	H8849_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	0	0	0	0	0	0	0	0	0				0		0
H8849	006	0	1	02	01	H8849_006_0	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	006	0	1	02	01	H8849_006_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								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			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	006	0	1	02	01	H8849_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											52.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H8849	006	0	1	02	01	H8849_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											23.00	30	30	30				13.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H8849	006	0	1	02	01	H8849_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34											67.87	33						46.67	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	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																														
H8849	009	0	1	02	01	H8849_009_0	5			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																														
H8849	009	0	1	02	01	H8849_009_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																														
H8849	009	0	1	02	01	H8849_009_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											55.00	25	25	25				70.00	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	25	25	25	20	20	20	20	20	20				25		25
H8849	009	0	1	02	01	H8849_009_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											28.00	30	30	30				12.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H8849	009	0	1	02	01	H8849_009_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																														
H8849	009	0	1	02	01	H8849_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	010	1	1	01	01	H8849_010_1	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	010	1	1	01	01	H8849_010_1	7		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, Select Care Drugs																														
H8849	010	1	1	01	01	H8849_010_1	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	1	1	01	01	H8849_010_1	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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	1	1	01	01	H8849_010_1	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, Select Care Drugs																														
H8849	010	1	1	01	01	H8849_010_1	7		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																														
H8849	010	2	1	01	01	H8849_010_2	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	010	2	1	01	01	H8849_010_2	7		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, Select Care Drugs																														
H8849	010	2	1	01	01	H8849_010_2	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	2	1	01	01	H8849_010_2	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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	2	1	01	01	H8849_010_2	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, Select Care Drugs																														
H8849	010	2	1	01	01	H8849_010_2	7		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																														
H8849	010	4	1	01	01	H8849_010_4	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	010	4	1	01	01	H8849_010_4	7		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, Select Care Drugs																														
H8849	010	4	1	01	01	H8849_010_4	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	4	1	01	01	H8849_010_4	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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	4	1	01	01	H8849_010_4	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, Select Care Drugs																														
H8849	010	4	1	01	01	H8849_010_4	7		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																														
H8849	010	5	1	01	01	H8849_010_5	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	010	5	1	01	01	H8849_010_5	7		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, Select Care Drugs																														
H8849	010	5	1	01	01	H8849_010_5	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				93.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	5	1	01	01	H8849_010_5	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				31.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	010	5	1	01	01	H8849_010_5	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, Select Care Drugs																														
H8849	010	5	1	01	01	H8849_010_5	7		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																														
H8849	011	1	1	01	01	H8849_011_1	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	1	1	01	01	H8849_011_1	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	1	1	01	01	H8849_011_1	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				89.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	1	1	01	01	H8849_011_1	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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	1	1	01	01	H8849_011_1	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, Select Care Drugs																														
H8849	011	1	1	01	01	H8849_011_1	7		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																														
H8849	011	2	1	01	01	H8849_011_2	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	2	1	01	01	H8849_011_2	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	2	1	01	01	H8849_011_2	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				89.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	2	1	01	01	H8849_011_2	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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	2	1	01	01	H8849_011_2	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, Select Care Drugs																														
H8849	011	2	1	01	01	H8849_011_2	7		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																														
H8849	011	3	1	01	01	H8849_011_3	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	3	1	01	01	H8849_011_3	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	3	1	01	01	H8849_011_3	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				89.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	3	1	01	01	H8849_011_3	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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	3	1	01	01	H8849_011_3	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, Select Care Drugs																														
H8849	011	3	1	01	01	H8849_011_3	7		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																														
H8849	011	4	1	01	01	H8849_011_4	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	4	1	01	01	H8849_011_4	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	4	1	01	01	H8849_011_4	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				89.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	4	1	01	01	H8849_011_4	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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	4	1	01	01	H8849_011_4	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, Select Care Drugs																														
H8849	011	4	1	01	01	H8849_011_4	7		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																														
H8849	011	5	1	01	01	H8849_011_5	7		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		34	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	5	1	01	01	H8849_011_5	7		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8849	011	5	1	01	01	H8849_011_5	7		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				89.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	5	1	01	01	H8849_011_5	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				25.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8849	011	5	1	01	01	H8849_011_5	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, Select Care Drugs																														
H8849	011	5	1	01	01	H8849_011_5	7		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																														
H8854	002	0	1	01	01	H8854_002_0	7		N	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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H8854	002	0	1	01	01	H8854_002_0	7		N	Generic	4	01	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	25	25	25				25	25	25				25		25
H8854	002	0	1	01	01	H8854_002_0	7		N	Preferred Brand	4	10	1	1	3	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31				45.96	25	25	25																		25	25	25																25		25								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	25	25	25				25	25	25				25		25
H8854	002	0	1	01	01	H8854_002_0	7		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	90				2	2	30	60	90					10	31				55.42	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8854	002	0	1	01	01	H8854_002_0	7		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				486.54	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H8879	001	0	1	02	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	02	01	H8879_001_0	8			Generic	4	01	1	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	10.00		30.00	0.00		0.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	0		0	25		25	0		0	25		25
H8879	001	0	1	02	01	H8879_001_0	8			Preferred Brand	4	10	1	2	3	1		110	01		110	1				30		100	1	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	35.00		105.00	0.00		0.00	35.00		105.00	0.00		0.00	35.00		35.00	25		25	0		0	25		25	0		0	25		25
H8879	001	0	1	02	01	H8879_001_0	8			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					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	35.00		105.00	0.00		0.00	35.00		105.00	0.00		0.00	35.00		35.00	25		25	0		0	25		25	0		0	25		25
H8879	001	0	1	02	01	H8879_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											653.97	33						605.59	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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	9.00	18.00	27.00																									20.00	40.00	60.00				9.00	18.00	27.00				9.00				9.00		0.30				0.67	0.30	0.29	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				45.30	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	30.00	60.00	90.00	35.00		35.00	19	19	19				19	19	19	19	19	19	19		19
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				77.70	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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								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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	11.00	22.00	33.00																									20.00	40.00	60.00				11.00	22.00	33.00				11.00				11.00		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				56.38	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	30.00	60.00	90.00	35.00		35.00	21	21	21				21	21	21	21	21	21	21		21
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				75.44	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	003	0	1	04	01	H8889_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																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	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																									20.00	40.00	60.00				10.00	20.00	30.00				10.00				10.00		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	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				40.71	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	30.00	60.00	90.00	35.00		35.00	19	19	19				19	19	19	19	19	19	19		19
H8889	003	0	1	04	01	H8889_003_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				64.81	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	003	0	1	04	01	H8889_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					31																										31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	9.00	18.00	27.00																									20.00	40.00	60.00				9.00	18.00	27.00				9.00				9.00		0.30				0.67	0.30	0.29	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				37.51	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	30.00	60.00	90.00	35.00		35.00	17	17	17				17	17	17	17	17	17	17		17
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				71.62	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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								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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		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	9.00	18.00	27.00																									20.00	40.00	60.00				9.00	18.00	27.00				9.00				9.00		0.30				0.67	0.30	0.29	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				43.79	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	30.00	60.00	90.00	35.00		35.00	17	17	17				17	17	17	17	17	17	17		17
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				70.40	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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					25																										25						25					25			25								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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	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	9.00	18.00	27.00																									20.00	40.00	60.00				9.00	18.00	27.00				9.00				9.00		0.30				0.67	0.30	0.29	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				42.25	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	30.00	60.00	90.00	35.00		35.00	17	17	17				17	17	17	17	17	17	17		17
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				73.30	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	010	0	1	04	01	H8889_010_0	5			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	010	0	1	04	01	H8889_010_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									20.00	40.00	60.00				5.00	10.00	15.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	010	0	1	04	01	H8889_010_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				44.38	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	30.00	60.00	90.00	35.00		35.00	18	18	18				18	18	18	18	18	18	18		18
H8889	010	0	1	04	01	H8889_010_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				70.20	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	010	0	1	04	01	H8889_010_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								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																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	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	7.00	14.00	21.00																									20.00	40.00	60.00				7.00	14.00	21.00				7.00				7.00		0.23				0.67	0.23	0.23	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				47.04	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	30.00	60.00	90.00	35.00		35.00	20	20	20				20	20	20	20	20	20	20		20
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				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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	012	0	1	04	01	H8889_012_0	5			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	012	0	1	04	01	H8889_012_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	8.00	16.00	24.00																									20.00	40.00	60.00				8.00	16.00	24.00				8.00				8.00		0.27				0.67	0.27	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	012	0	1	04	01	H8889_012_0	5			Preferred Brand	4	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				43.66	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	30.00	60.00	90.00	35.00		35.00	19	19	19				19	19	19	19	19	19	19		19
H8889	012	0	1	04	01	H8889_012_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				74.10	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	012	0	1	04	01	H8889_012_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	013	0	1	04	01	H8889_013_0	5			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	013	0	1	04	01	H8889_013_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	7.00	14.00	21.00																									20.00	40.00	60.00				7.00	14.00	21.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	013	0	1	04	01	H8889_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				45.09	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	30.00	60.00	90.00	35.00		35.00	21	21	21				21	21	21	21	21	21	21		21
H8889	013	0	1	04	01	H8889_013_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				64.09	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	013	0	1	04	01	H8889_013_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					30																										30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	014	0	1	04	01	H8889_014_0	5			Preferred Generic	4	01	1	2	1	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	014	0	1	04	01	H8889_014_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	6.00	12.00	18.00																									20.00	40.00	60.00				6.00	12.00	18.00				6.00				6.00		0.20				0.67	0.20	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	014	0	1	04	01	H8889_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				36.32	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	30.00	60.00	90.00	35.00		35.00	16	16	16				16	16	16	16	16	16	16		16
H8889	014	0	1	04	01	H8889_014_0	5			Non-Preferred Drug	4	11	1	1	4	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				77.86	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	014	0	1	04	01	H8889_014_0	5			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30											30			30		31					25																										25						25					25			25								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																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	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	7.00	14.00	21.00																									20.00	40.00	60.00				7.00	14.00	21.00				7.00				7.00		0.23				0.67	0.23	0.23	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				44.78	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	30.00	60.00	90.00	35.00		35.00	18	18	18				18	18	18	18	18	18	18		18
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				78.35	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
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					29																										29						29					29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	017	0	1	04	01	H8889_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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	017	0	1	04	01	H8889_017_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	5.00	10.00	15.00																									20.00	40.00	60.00				5.00	10.00	15.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	017	0	1	04	01	H8889_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				42.40	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	30.00	60.00	90.00	35.00		35.00	18	18	18				18	18	18	18	18	18	18		18
H8889	017	0	1	04	01	H8889_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				80.35	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	017	0	1	04	01	H8889_017_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																														
H8889	018	0	1	04	01	H8889_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	0.00	0.00	0.00																									10.00	20.00	30.00				0.00	0.00	0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	018	0	1	04	01	H8889_018_0	5			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	7.00	14.00	21.00																									20.00	40.00	60.00				7.00	14.00	21.00				7.00				7.00		0.23				0.67	0.23	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8889	018	0	1	04	01	H8889_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				47.76	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	30.00	60.00	90.00	35.00		35.00	20	20	20				20	20	20	20	20	20	20		20
H8889	018	0	1	04	01	H8889_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				80.98	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	30.00	60.00	90.00	35.00		35.00	25	25	25				25	25	25	25	25	25	25		25
H8889	018	0	1	04	01	H8889_018_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																														
H8894	001	0	1	01	01	H8894_001_0	6		N	Preferred Generic	4	01	1	2	1	1	110		01	100		1	31		100				2	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, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H8894	001	0	1	01	01	H8894_001_0	6		N	Generic	4	11	1	1	2	1	110		01	100		1	31		100				2	2			100				31		31				8.84	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8894	001	0	1	01	01	H8894_001_0	6		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	31		100				2	2			100				31		31				124.32	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8894	001	0	1	01	01	H8894_001_0	6		N	Non-Preferred Drug	4	11	1	1	4	1	110		01	100		1	31		100				2	2			100				31		31				74.62	30		30																				30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
H8894	001	0	1	01	01	H8894_001_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				466.70	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	25						25						25		25
H8894	001	0	1	01	01	H8894_001_0	6		N	Select Care Drugs	4	11	1	2	6	1	110		01	100		1	31		100				2	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, Select Care Drugs	0.00		0.00						0.00				0.00		0.00	0		0						0				0		0
H8902	002	0	1	01	01	H8902_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	0.00				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	7			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8902	002	0	1	01	01	H8902_002_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					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	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H8902	002	0	1	01	01	H8902_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											47.39	35	35	35				47.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	002	0	1	01	01	H8902_002_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8902	009	0	1	01	01	H8902_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	0.00				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	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																														
H8902	009	0	1	01	01	H8902_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											102.35	25	25	25				102.35	24	24	24										25	25	25				24	24	24			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	0.00	0.00	0.00	0.00	0.00		0.00	0	0	0	0	0	0	0	0	0	0	0	0	0		0
H8902	009	0	1	01	01	H8902_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											59.83	30	30	30				59.83	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	009	0	1	01	01	H8902_009_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																														
H8902	010	0	1	01	01	H8902_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								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				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	6			Generic	4	11	1	2	2	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								7.00	14.00	14.00					0.00	0.00	0.00											7.00	14.00	14.00				0.00	0.00	0.00				7.00				7.00			0.23	0.00		0.23	0.00	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8902	010	0	1	01	01	H8902_010_0	6			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								47.00	94.00	141.00					42.00	84.00	126.00											47.00	94.00	141.00				42.00	84.00	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	010	0	1	01	01	H8902_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											48.30	35	35	35				48.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	010	0	1	01	01	H8902_010_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																														
H8902	011	0	1	01	01	H8902_011_0	7			Preferred Generic	4	11	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				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	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																														
H8902	011	0	1	01	01	H8902_011_0	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	011	0	1	01	01	H8902_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											45.80	35	35	35				45.80	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H8902	011	0	1	01	01	H8902_011_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												33							33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H8908	001	0	1	02	01	H8908_001_0	2			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	0		0				25		25	0		0	0		0
H8908	001	0	1	02	01	H8908_001_0	2			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	25		25				25		25	25		0	25		25
H8908	001	0	1	02	01	H8908_001_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
H8908	001	0	1	02	01	H8908_001_0	2			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	25		25				25		25	25		25	25		25
H8908	001	0	1	02	01	H8908_001_0	2			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	25						25			25			25		25
H8908	004	0	1	02	01	H8908_004_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	0		0				25		25	0		0	0		0
H8908	004	0	1	02	01	H8908_004_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	0		0				25		25	0		0	0		0
H8908	004	0	1	02	01	H8908_004_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	25		25				25		25	25		25	25		25
H8908	004	0	1	02	01	H8908_004_0	3			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	25		25				25		25	25		25	25		25
H8908	004	0	1	02	01	H8908_004_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	25						25			25			25		25
H8908	005	0	1	01	01	H8908_005_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	0		0				25		25	0		0	0		0
H8908	005	0	1	01	01	H8908_005_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	0		0				25		25	0		0	0		0
H8908	005	0	1	01	01	H8908_005_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H8908	005	0	1	01	01	H8908_005_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H8908	005	0	1	01	01	H8908_005_0	5		N	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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
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	0		0				25		25	0		0	0		0
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	25		25				25		25	25		25	25		25
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				84.00	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	25		25				25		25	25		25	25		25
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	25						25			25			25		25
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	0		0				25		25	0		0	0		0
H8908	007	0	1	01	01	H8908_007_0	3		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	0		0				25		25	0		0	0		0
H8908	007	0	1	01	01	H8908_007_0	3		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	0		0				25		25	0		0	0		0
H8908	007	0	1	01	01	H8908_007_0	3		N	Preferred Brand	4	11	1	1	3	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H8908	007	0	1	01	01	H8908_007_0	3		N	Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		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		105.00				35.00		105.00	35.00		105.00	35.00		35.00	25		25				25		25	25		25	25		25
H8908	007	0	1	01	01	H8908_007_0	3		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	25						25			25			25		25
H8917	001	0	1	04	01	H8917_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	0	0	0				0	0	0				0		0
H8917	001	0	1	04	01	H8917_001_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	0	0	0				0	0	0				0		0
H8917	001	0	1	04	01	H8917_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				33.00	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	19	19	19				19	19	19				19		19
H8917	001	0	1	04	01	H8917_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				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	25	25	25				25	25	25				25		25
H8917	001	0	1	04	01	H8917_001_0	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	25						25						25		25
H8917	002	0	1	04	01	H8917_002_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	0	0	0				0	0	0				0		0
H8917	002	0	1	04	01	H8917_002_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	25	25	25				25	25	25				25		25
H8917	002	0	1	04	01	H8917_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				39.00	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	21	21	21				21	21	21				21		21
H8917	002	0	1	04	01	H8917_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				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	25	25	25				25	25	25				25		25
H8917	002	0	1	04	01	H8917_002_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	25						25						25		25
H8917	005	0	1	04	01	H8917_005_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8917	005	0	1	04	01	H8917_005_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8917	005	0	1	04	01	H8917_005_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H8917	005	0	1	04	01	H8917_005_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H8917	005	0	1	04	01	H8917_005_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8917	005	0	1	04	01	H8917_005_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8917	006	0	1	04	01	H8917_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H8917	006	0	1	04	01	H8917_006_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H8917	006	0	1	04	01	H8917_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H8917	006	0	1	04	01	H8917_006_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H8917	006	0	1	04	01	H8917_006_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H8917	006	0	1	04	01	H8917_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8947	001	1	1	04	01	H8947_001_1	4			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 Drug, Specialty Tier																														
H8947	001	1	1	04	01	H8947_001_1	4			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 Drug, Specialty Tier																														
H8947	001	1	1	04	01	H8947_001_1	4			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	1	1	04	01	H8947_001_1	4			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	1	1	04	01	H8947_001_1	4			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 Drug, Specialty Tier																														
H8947	001	2	1	04	01	H8947_001_2	4			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 Drug, Specialty Tier																														
H8947	001	2	1	04	01	H8947_001_2	4			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 Drug, Specialty Tier																														
H8947	001	2	1	04	01	H8947_001_2	4			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	2	1	04	01	H8947_001_2	4			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	2	1	04	01	H8947_001_2	4			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 Drug, Specialty Tier																														
H8947	001	3	1	04	01	H8947_001_3	4			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 Drug, Specialty Tier																														
H8947	001	3	1	04	01	H8947_001_3	4			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 Drug, Specialty Tier																														
H8947	001	3	1	04	01	H8947_001_3	4			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	3	1	04	01	H8947_001_3	4			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	3	1	04	01	H8947_001_3	4			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 Drug, Specialty Tier																														
H8947	001	4	1	04	01	H8947_001_4	4			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 Drug, Specialty Tier																														
H8947	001	4	1	04	01	H8947_001_4	4			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 Drug, Specialty Tier																														
H8947	001	4	1	04	01	H8947_001_4	4			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	4	1	04	01	H8947_001_4	4			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	001	4	1	04	01	H8947_001_4	4			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 Drug, Specialty Tier																														
H8947	002	1	1	04	01	H8947_002_1	5			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 Drug, Specialty Tier																														
H8947	002	1	1	04	01	H8947_002_1	5			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 Drug, Specialty Tier																														
H8947	002	1	1	04	01	H8947_002_1	5			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	1	1	04	01	H8947_002_1	5			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	1	1	04	01	H8947_002_1	5			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 Drug, Specialty Tier																														
H8947	002	2	1	04	01	H8947_002_2	5			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 Drug, Specialty Tier																														
H8947	002	2	1	04	01	H8947_002_2	5			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 Drug, Specialty Tier																														
H8947	002	2	1	04	01	H8947_002_2	5			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	2	1	04	01	H8947_002_2	5			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	2	1	04	01	H8947_002_2	5			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 Drug, Specialty Tier																														
H8947	002	3	1	04	01	H8947_002_3	5			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 Drug, Specialty Tier																														
H8947	002	3	1	04	01	H8947_002_3	5			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 Drug, Specialty Tier																														
H8947	002	3	1	04	01	H8947_002_3	5			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	3	1	04	01	H8947_002_3	5			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	3	1	04	01	H8947_002_3	5			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 Drug, Specialty Tier																														
H8947	002	4	1	04	01	H8947_002_4	5			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 Drug, Specialty Tier																														
H8947	002	4	1	04	01	H8947_002_4	5			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 Drug, Specialty Tier																														
H8947	002	4	1	04	01	H8947_002_4	5			Preferred Brand	4	11	1	2	3	1		110	01	110		1				30		90	1	2	30		90				30		31								47.00		141.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	4	1	04	01	H8947_002_4	5			Non-Preferred Drug	4	11	1	2	4	1		110	01	110		1				30		90	1	2	30		90				30		31								100.00		300.00					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 Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00				35.00		35.00	25		25	25		25	25		25				25		25
H8947	002	4	1	04	01	H8947_002_4	5			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 Drug, Specialty Tier																														
H8967	002	0	1	01	01	H8967_002_0	6			Preferred Generic	4	01	1	2	1	1	111		10			1	30	60	90				2	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H8967	002	0	1	01	01	H8967_002_0	6			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	25	25	25										25		25
H8967	002	0	1	01	01	H8967_002_0	6			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	25	25	25										25		25
H8967	002	0	1	01	01	H8967_002_0	6			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	25	25	25										25		25
H8967	002	0	1	01	01	H8967_002_0	6			Specialty Tier	4	11	1	1	5	1	111		10			1	30	60	90				2	2								10	31				466.21	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	6			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	6			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																														
H9001	030	15	1	01	01	H9001_030_15	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	15	1	01	01	H9001_030_15	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	030	15	1	01	01	H9001_030_15	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				98.71	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	030	15	1	01	01	H9001_030_15	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	15	1	01	01	H9001_030_15	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	16	1	01	01	H9001_030_16	6			Preferred Generic	4	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																														
H9001	030	16	1	01	01	H9001_030_16	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	16	1	01	01	H9001_030_16	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	030	16	1	01	01	H9001_030_16	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				98.71	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	030	16	1	01	01	H9001_030_16	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	16	1	01	01	H9001_030_16	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	18	1	01	01	H9001_030_18	6			Preferred Generic	4	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																														
H9001	030	18	1	01	01	H9001_030_18	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	18	1	01	01	H9001_030_18	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	030	18	1	01	01	H9001_030_18	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				98.71	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	030	18	1	01	01	H9001_030_18	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	030	18	1	01	01	H9001_030_18	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	15	1	01	01	H9001_031_15	6			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																														
H9001	031	15	1	01	01	H9001_031_15	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	15	1	01	01	H9001_031_15	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	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	25	25	25				25	25	25				25		25
H9001	031	15	1	01	01	H9001_031_15	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				59.83	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	031	15	1	01	01	H9001_031_15	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	15	1	01	01	H9001_031_15	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	16	1	01	01	H9001_031_16	6			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																														
H9001	031	16	1	01	01	H9001_031_16	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	16	1	01	01	H9001_031_16	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	031	16	1	01	01	H9001_031_16	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				59.83	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	031	16	1	01	01	H9001_031_16	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	16	1	01	01	H9001_031_16	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	18	1	01	01	H9001_031_18	6			Preferred Generic	4	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																														
H9001	031	18	1	01	01	H9001_031_18	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	18	1	01	01	H9001_031_18	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	031	18	1	01	01	H9001_031_18	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31				59.83	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	031	18	1	01	01	H9001_031_18	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	031	18	1	01	01	H9001_031_18	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	038	0	1	01	01	H9001_038_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				2	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	038	0	1	01	01	H9001_038_0	6			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	7.00	14.00	21.00																			7.00	14.00	14.00																7.00				7.00		0.23			0.23			0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	038	0	1	01	01	H9001_038_0	6			Preferred Brand	4	11	1	2	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		31	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	25	25	25				25	25	25				25		25
H9001	038	0	1	01	01	H9001_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		31				75.71	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9001	038	0	1	01	01	H9001_038_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					28																				28																	28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9001	038	0	1	01	01	H9001_038_0	6			Select Care Drugs	4	11	1	2	6	1	010		01	010		1	30								30						30		31	0.00																					0.00																		0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9003	001	0	1	02	01	H9003_001_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9003	001	0	1	02	01	H9003_001_0	4			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	25	25	25				25	25	25				25		25
H9003	001	0	1	02	01	H9003_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	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	25	25	25				25	25	25				25		25
H9003	001	0	1	02	01	H9003_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	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	25	25	25				25	25	25				25		25
H9003	001	0	1	02	01	H9003_001_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								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	25	25	25				25	25	25				25		25
H9003	001	0	1	02	01	H9003_001_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9003	006	0	1	02	01	H9003_006_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, Vaccines	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9003	006	0	1	02	01	H9003_006_0	4			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	25	25	25				25	25	25				25		25
H9003	006	0	1	02	01	H9003_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	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	25	25	25				25	25	25				25		25
H9003	006	0	1	02	01	H9003_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	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	25	25	25				25	25	25				25		25
H9003	006	0	1	02	01	H9003_006_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								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	25	25	25				25	25	25				25		25
H9003	006	0	1	02	01	H9003_006_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9003	008	0	1	02	01	H9003_008_0	4			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	25	25	25	0	0	0	0	0	0				25		25
H9003	008	0	1	02	01	H9003_008_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					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, Vaccines	20.00	40.00	60.00	10.00	20.00	30.00	10.00	20.00	20.00				20.00		20.00	25	25	25	25	25	25	25	25	25				25		25
H9003	008	0	1	02	01	H9003_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					40.00	80.00	120.00					40.00	80.00	80.00																47.00				47.00			1.57	1.33	1.33			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	35.00	70.00	80.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9003	008	0	1	02	01	H9003_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					93.00	186.00	279.00					93.00	186.00	186.00																100.00				100.00			3.33	3.10	3.10			3.23	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	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9003	008	0	1	02	01	H9003_008_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	25	25	25	25	25	25	25	25	25				25		25
H9003	008	0	1	02	01	H9003_008_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																														
H9003	009	0	1	02	01	H9003_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	0.00	0.00	0.00																			0.00	0.00	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	0	0	0				0	0	0				0		0
H9003	009	0	1	02	01	H9003_009_0	4			Generic	4	11	1	2	2	1	111		01	111		1	30	60	90				2	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, Vaccines	5.00	10.00	15.00				5.00	10.00	10.00				5.00		5.00	25	25	25				25	25	25				25		25
H9003	009	0	1	02	01	H9003_009_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	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	25	25	25				25	25	25				25		25
H9003	009	0	1	02	01	H9003_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	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	25	25	25				25	25	25				25		25
H9003	009	0	1	02	01	H9003_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								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	25	25	25				25	25	25				25		25
H9003	009	0	1	02	01	H9003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9042	004	0	1	04	01	H9042_004_0	7			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					2.00	4.00	0.00																	0.00			0.00			0.00	0.00	0.07			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	2.00	4.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H9042	004	0	1	04	01	H9042_004_0	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					8.00	16.00	0.00																	0.00			0.00			0.00	0.00	0.27			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	8.00	16.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H9042	004	0	1	04	01	H9042_004_0	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25				25		25
H9042	004	0	1	04	01	H9042_004_0	7			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											83.84	28	28	28				83.13	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	25	25	25	25	25	25	25	25	25				25		25
H9042	004	0	1	04	01	H9042_004_0	7			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	25			25									25		25
H9042	004	0	1	04	01	H9042_004_0	7			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	100	1	2	30	60	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	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	0	0	0	0	0	0	0	0	0				0		0
H9042	007	0	1	04	01	H9042_007_0	7			Preferred Generic	4	11	3	2	1	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					2.00	4.00	0.00																	0.00			0.00			0.00	0.00	0.07			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	2.00	4.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H9042	007	0	1	04	01	H9042_007_0	7			Generic	4	11	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					10	31								0.00	0.00	0.00					0.00	0.00	0.00					8.00	16.00	0.00																	0.00			0.00			0.00	0.00	0.27			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	8.00	16.00	0.00				0.00		0.00	0	0	0	0	0	0	25	25	0				0		0
H9042	007	0	1	04	01	H9042_007_0	7			Preferred Brand	4	11	1	2	3	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31								47.00	94.00	141.00					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	25	25	25	25	25	25	25	25	25				25		25
H9042	007	0	1	04	01	H9042_007_0	7			Non-Preferred Brand	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					10	31											72.82	28	28	28				78.94	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	25	25	25	25	25	25	25	25	25				25		25
H9042	007	0	1	04	01	H9042_007_0	7			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												10	31												29							29																								29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Brand, Specialty Tier, Select Care Drugs	35.00			35.00									35.00		35.00	25			25									25		25
H9042	007	0	1	04	01	H9042_007_0	7			Select Care Drugs	4	11	1	2	6	1		111	10	111		1				30	60	100	1	2	30	60	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	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	0	0	0	0	0	0	0	0	0				0		0
H9047	013	0	2	01	01	H9047_013_0	9			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	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					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	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					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	25	25	25	25	25	25	25	25	25				25		25
H9047	013	0	2	01	01	H9047_013_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					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	25	25	25	25	25	25	25	25	25				25		25
H9047	013	0	2	01	01	H9047_013_0	9			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											531.13	33						807.26	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	037	0	1	01	01	H9047_037_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	037	0	1	01	01	H9047_037_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					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	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					40.00	80.00	120.00																47.00				47.00			1.57	1.57	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	037	0	1	01	01	H9047_037_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	037	0	1	01	01	H9047_037_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											859.67	30						601.60	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	054	0	1	01	01	H9047_054_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	054	0	1	01	01	H9047_054_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					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	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					40.00	80.00	120.00																47.00				47.00			1.57	1.57	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	054	0	1	01	01	H9047_054_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	054	0	1	01	01	H9047_054_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											643.63	30						564.71	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	063	0	1	01	01	H9047_063_0	11			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	063	0	1	01	01	H9047_063_0	11			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					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	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					40.00	80.00	120.00																47.00				47.00			1.57	1.57	1.33			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	063	0	1	01	01	H9047_063_0	11			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	063	0	1	01	01	H9047_063_0	11			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											411.18	30						535.20	30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	064	0	1	01	01	H9047_064_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								12.00	24.00	36.00					0.00	0.00	0.00					0.00	0.00	0.00																12.00				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	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					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	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					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	25	25	25	25	25	25	25	25	25				25		25
H9047	064	0	1	01	01	H9047_064_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					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	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	064	0	1	01	01	H9047_064_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											446.59	33						743.43	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	066	0	1	01	01	H9047_066_0	10			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								16.00	32.00	48.00					0.00	0.00	0.00					0.00	0.00	0.00																16.00				16.00			0.53	0.00	0.00			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9047	066	0	1	01	01	H9047_066_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					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	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					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	25	25	25	25	25	25	25	25	25				25		25
H9047	066	0	1	01	01	H9047_066_0	10			Non-Preferred Drug	4	11	1	2	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								100.00	200.00	300.00					100.00	200.00	300.00					100.00	200.00	300.00																100.00				100.00			3.33	3.33	3.33			3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	95.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9047	066	0	1	01	01	H9047_066_0	10			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											1073.33	33						586.41	33						33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9065	001	0	1	01	01	H9065_001_0	6		N	Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	90				1	2	30	60	90				30		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	001	0	1	01	01	H9065_001_0	6		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				4.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	001	0	1	01	01	H9065_001_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				71.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9065	001	0	1	01	01	H9065_001_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				32.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9065	001	0	1	01	01	H9065_001_0	6		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																														
H9065	001	0	1	01	01	H9065_001_0	6		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																														
H9065	002	0	1	02	01	H9065_002_0	5			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											58.00	25	25	25				85.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9065	002	0	1	02	01	H9065_002_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											29.00	30	30	30				20.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9065	002	0	1	02	01	H9065_002_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	002	0	1	02	01	H9065_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	6			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				5.00			0.17	0.00	0.00			0.15	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	003	0	1	02	01	H9065_003_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								7.00	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			0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	003	0	1	02	01	H9065_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											55.00	25	25	25				82.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9065	003	0	1	02	01	H9065_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											33.00	30	30	30				21.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9065	003	0	1	02	01	H9065_003_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																														
H9065	003	0	1	02	01	H9065_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			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	008	0	1	01	01	H9065_008_0	5			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																														
H9065	008	0	1	01	01	H9065_008_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																														
H9065	008	0	1	01	01	H9065_008_0	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											64.00	25	25	25				68.00	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	25	25	25	20	20	20	20	20	20				25		25
H9065	008	0	1	01	01	H9065_008_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											27.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9065	008	0	1	01	01	H9065_008_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9065	008	0	1	01	01	H9065_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	4			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					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, Vaccines																														
H9096	001	0	1	02	01	H9096_001_0	4			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								16.00	32.00	32.00					11.00	22.00	22.00					11.00	22.00	22.00																	16.00			16.00			0.53	0.37	0.37			0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9096	001	0	1	02	01	H9096_001_0	4			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											66.95	25	25	25				52.44	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	25	25	25	20	20	20	20	20	20				25		25
H9096	001	0	1	02	01	H9096_001_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											47.70	50	50	50				47.88	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	25	25	25	25	25	25	25	25	25				25		25
H9096	001	0	1	02	01	H9096_001_0	4			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	001	0	1	02	01	H9096_001_0	4			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	4			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					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, Vaccines																														
H9096	002	0	1	02	01	H9096_002_0	4			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								19.00	38.00	38.00					14.00	28.00	28.00					14.00	28.00	28.00																	19.00			19.00			0.63	0.47	0.47			0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9096	002	0	1	02	01	H9096_002_0	4			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											67.96	25	25	25				50.95	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	25	25	25	20	20	20	20	20	20				25		25
H9096	002	0	1	02	01	H9096_002_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											58.80	50	50	50				54.28	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	25	25	25	25	25	25	25	25	25				25		25
H9096	002	0	1	02	01	H9096_002_0	4			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	002	0	1	02	01	H9096_002_0	4			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					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, 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								11.00	22.00	22.00					5.00	10.00	10.00					5.00	10.00	10.00																	11.00			11.00			0.37	0.17	0.17			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
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											69.24	25	25	25				53.39	20	20	20				20	20	20																20		20								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	20	20	20	20	20	20	20	20	20				20		20
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											60.31	50	50	50				47.76	45	45	45				45	45	45																45		45								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	25	25	25	25	25	25	25	25	25				25		25
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												25							25																								25		25								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	4			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					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, Vaccines																														
H9096	005	0	1	01	01	H9096_005_0	4			Generic	4	11	1	2	2	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31								20.00	40.00	40.00					15.00	30.00	30.00					15.00	30.00	30.00																	20.00			20.00			0.67	0.50	0.50			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9096	005	0	1	01	01	H9096_005_0	4			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											64.23	25	25	25				48.27	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	30.00	30.00				35.00		35.00	25	25	25	20	20	20	20	20	20				25		25
H9096	005	0	1	01	01	H9096_005_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	90	1	2	30	60	90					29	31											40.60	50	50	50				40.70	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	60.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
H9096	005	0	1	01	01	H9096_005_0	4			Specialty Tier	4	11	1	1	5	1		010	10	000		1				30												29	31												31							31																								31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines																														
H9096	005	0	1	01	01	H9096_005_0	4			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	11		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	25	25	25				25	25	25				25		25
H9147	001	0	1	02	01	H9147_001_0	11		N	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																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9147	001	0	1	02	01	H9147_001_0	11		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9147	001	0	1	02	01	H9147_001_0	11		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				63.80	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		35.00	25	25	25				25	25	25				25		25
H9147	001	0	1	02	01	H9147_001_0	11		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				486.30	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	11		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																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	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	0	0	0				0	0	0				0		0
H9179	001	0	1	01	01	H9179_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 Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9179	001	0	1	01	01	H9179_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				34.98	25	25	25																		25	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	25	25	25				25	25	25				25		25
H9179	001	0	1	01	01	H9179_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				83.09	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9179	001	0	1	01	01	H9179_001_0	7			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	35.00						35.00						35.00		35.00	25						25						25		25
H9179	002	0	1	01	01	H9179_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	0	0	0				0	0	0				0		0
H9179	002	0	1	01	01	H9179_002_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	25	25	25				0	0	0				25		25
H9179	002	0	1	01	01	H9179_002_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				41.86	25	25	25																		25	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	25	25	25				25	25	25				25		25
H9179	002	0	1	01	01	H9179_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				65.30	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	25	25	25				25	25	25				25		25
H9179	002	0	1	01	01	H9179_002_0	7			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	35.00						35.00						35.00		35.00	25						25						25		25
H9207	002	0	1	01	01	H9207_002_0	16			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9207	002	0	1	01	01	H9207_002_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			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	16			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.89	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	002	0	1	01	01	H9207_002_0	16			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				65.44	28	28	28																		28	28	28															28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	002	0	1	01	01	H9207_002_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1092.67	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9207	004	0	1	01	01	H9207_004_0	18		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, Select Care Drugs																														
H9207	004	0	1	01	01	H9207_004_0	18		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.55	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9207	004	0	1	01	01	H9207_004_0	18		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				50.18	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	24	24	24				24	24	24				24		24
H9207	004	0	1	01	01	H9207_004_0	18		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				60.47	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	25	25	25				25	25	25				25		25
H9207	004	0	1	01	01	H9207_004_0	18		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				884.88	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	25						25						25		25
H9207	004	0	1	01	01	H9207_004_0	18		N	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																														
H9207	012	0	1	01	01	H9207_012_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																														
H9207	012	0	1	01	01	H9207_012_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	5.00	10.00	15.00																			5.00	10.00	10.00																5.00				5.00		0.17			0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9207	012	0	1	01	01	H9207_012_0	16			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.69	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	012	0	1	01	01	H9207_012_0	16			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.73	34	34	34																		34	34	34															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	012	0	1	01	01	H9207_012_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1060.05	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9207	013	0	1	01	01	H9207_013_0	19			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9207	013	0	1	01	01	H9207_013_0	19			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			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	19			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				80.63	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	013	0	1	01	01	H9207_013_0	19			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				72.26	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	25	25	25				25	25	25				25		25
H9207	013	0	1	01	01	H9207_013_0	19			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1428.80	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9207	015	0	1	01	01	H9207_015_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																														
H9207	015	0	1	01	01	H9207_015_0	16			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	10.00	20.00	30.00																			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	16			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				57.26	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		35.00	20	20	20				20	20	20				20		20
H9207	015	0	1	01	01	H9207_015_0	16			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				86.35	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		35.00	25	25	25				25	25	25				25		25
H9207	015	0	1	01	01	H9207_015_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1126.50	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9207	016	0	1	01	01	H9207_016_0	16		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, Select Care Drugs																														
H9207	016	0	1	01	01	H9207_016_0	16		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				4.64	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9207	016	0	1	01	01	H9207_016_0	16		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				53.31	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	24	24	24				24	24	24				24		24
H9207	016	0	1	01	01	H9207_016_0	16		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				62.38	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	25	25	25				25	25	25				25		25
H9207	016	0	1	01	01	H9207_016_0	16		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				890.56	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	25						25						25		25
H9207	016	0	1	01	01	H9207_016_0	16		N	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																														
H9207	017	0	1	01	01	H9207_017_0	16		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.88	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9207	017	0	1	01	01	H9207_017_0	16		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.69	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9207	017	0	1	01	01	H9207_017_0	16		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.53	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	25	25	25				25	25	25				25		25
H9207	017	0	1	01	01	H9207_017_0	16		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				54.12	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	25	25	25				25	25	25				25		25
H9207	017	0	1	01	01	H9207_017_0	16		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				885.22	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	25						25						25		25
H9207	017	0	1	01	01	H9207_017_0	16		N	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																														
H9207	018	0	1	01	01	H9207_018_0	22			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	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	018	0	1	01	01	H9207_018_0	22			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 Drug, Specialty Tier																														
H9207	018	0	1	01	01	H9207_018_0	22			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				78.58	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	018	0	1	01	01	H9207_018_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				77.75	34	34	34																		34	34	34															34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9207	018	0	1	01	01	H9207_018_0	22			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1402.22	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9231	002	0	1	04	01	H9231_002_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	0	0	0				0	0	0				0		0
H9231	002	0	1	04	01	H9231_002_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	25	25	25				25	25	25				25		25
H9231	002	0	1	04	01	H9231_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				62.00	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	22	22	22				22	22	22				22		22
H9231	002	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	002	0	1	04	01	H9231_002_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	25						25						25		25
H9231	005	0	1	04	01	H9231_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9231	005	0	1	04	01	H9231_005_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	25	25	25				25	25	25				25		25
H9231	005	0	1	04	01	H9231_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				62.00	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	22	22	22				22	22	22				22		22
H9231	005	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	005	0	1	04	01	H9231_005_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	25						25						25		25
H9231	006	0	1	04	01	H9231_006_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9231	006	0	1	04	01	H9231_006_0	6			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	25	25	25				25	25	25				25		25
H9231	006	0	1	04	01	H9231_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				58.00	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	22	22	22				22	22	22				22		22
H9231	006	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	006	0	1	04	01	H9231_006_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	25						25						25		25
H9231	007	0	1	04	01	H9231_007_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	0	0	0				0	0	0				0		0
H9231	007	0	1	04	01	H9231_007_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																			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	25	25	25				25	25	25				25		25
H9231	007	0	1	04	01	H9231_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				62.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9231	007	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	007	0	1	04	01	H9231_007_0	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	25						25						25		25
H9231	010	0	1	04	01	H9231_010_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	0	0	0				0	0	0				0		0
H9231	010	0	1	04	01	H9231_010_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																			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	25	25	25				25	25	25				25		25
H9231	010	0	1	04	01	H9231_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				63.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9231	010	0	1	04	01	H9231_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				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		35.00	25	25	25				25	25	25				25		25
H9231	010	0	1	04	01	H9231_010_0	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	25						25						25		25
H9231	011	0	1	04	01	H9231_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9231	011	0	1	04	01	H9231_011_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	0	0	0				0	0	0				0		0
H9231	011	0	1	04	01	H9231_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				33.00	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	19	19	19				19	19	19				19		19
H9231	011	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	011	0	1	04	01	H9231_011_0	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	25						25						25		25
H9231	012	0	1	04	01	H9231_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9231	012	0	1	04	01	H9231_012_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	25	25	25				25	25	25				25		25
H9231	012	0	1	04	01	H9231_012_0	5			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				39.00	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	21	21	21				21	21	21				21		21
H9231	012	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	012	0	1	04	01	H9231_012_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	25						25						25		25
H9231	015	0	1	04	01	H9231_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9231	015	0	1	04	01	H9231_015_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																			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	25	25	25				25	25	25				25		25
H9231	015	0	1	04	01	H9231_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				60.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9231	015	0	1	04	01	H9231_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				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	25	25	25				25	25	25				25		25
H9231	015	0	1	04	01	H9231_015_0	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	25						25						25		25
H9231	016	0	1	04	01	H9231_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9231	016	0	1	04	01	H9231_016_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9231	016	0	1	04	01	H9231_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H9231	016	0	1	04	01	H9231_016_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9231	016	0	1	04	01	H9231_016_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9231	016	0	1	04	01	H9231_016_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9231	017	0	1	04	01	H9231_017_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9231	017	0	1	04	01	H9231_017_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9231	017	0	1	04	01	H9231_017_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H9231	017	0	1	04	01	H9231_017_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9231	017	0	1	04	01	H9231_017_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9231	017	0	1	04	01	H9231_017_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9231	018	0	1	04	01	H9231_018_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9231	018	0	1	04	01	H9231_018_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9231	018	0	1	04	01	H9231_018_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H9231	018	0	1	04	01	H9231_018_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9231	018	0	1	04	01	H9231_018_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9231	018	0	1	04	01	H9231_018_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9231	019	0	1	04	01	H9231_019_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9231	019	0	1	04	01	H9231_019_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9231	019	0	1	04	01	H9231_019_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H9231	019	0	1	04	01	H9231_019_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9231	019	0	1	04	01	H9231_019_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9231	019	0	1	04	01	H9231_019_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9231	020	0	1	04	01	H9231_020_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9231	020	0	1	04	01	H9231_020_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9231	020	0	1	04	01	H9231_020_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9231	020	0	1	04	01	H9231_020_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H9231	020	0	1	04	01	H9231_020_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9231	020	0	1	04	01	H9231_020_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9306	002	0	1	01	01	H9306_002_0	9			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Supplemental Drugs																														
H9306	002	0	1	01	01	H9306_002_0	9			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				2	2	30	60	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	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	0	0				0	0	0				0		0
H9306	002	0	1	01	01	H9306_002_0	9			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	25	25	25				25	25	25				25		25
H9306	002	0	1	01	01	H9306_002_0	9			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	25	25	25				25	25	25				25		25
H9306	002	0	1	01	01	H9306_002_0	9			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	9			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	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9306	008	1	1	01	01	H9306_008_1	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				2	2	30	60	100					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	25	25	25				25	25	25				25		25
H9306	008	1	1	01	01	H9306_008_1	7			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	25	25	25				25	25	25				25		25
H9306	008	1	1	01	01	H9306_008_1	7			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	25	25	25				25	25	25				25		25
H9306	008	1	1	01	01	H9306_008_1	7			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	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9306	008	2	1	01	01	H9306_008_2	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				2	2	30	60	100					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	25	25	25				25	25	25				25		25
H9306	008	2	1	01	01	H9306_008_2	7			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	25	25	25				25	25	25				25		25
H9306	008	2	1	01	01	H9306_008_2	7			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	25	25	25				25	25	25				25		25
H9306	008	2	1	01	01	H9306_008_2	7			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	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9306	009	1	1	01	01	H9306_009_1	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, 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	0	0				0	0	0				0		0
H9306	009	1	1	01	01	H9306_009_1	7			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	25	25	25				25	25	25				25		25
H9306	009	1	1	01	01	H9306_009_1	7			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	25	25	25				25	25	25				25		25
H9306	009	1	1	01	01	H9306_009_1	7			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	7			Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9306	009	2	1	01	01	H9306_009_2	7			Generic	4	11	1	2	2	1	111		10	111		1	30	60	100				2	2	30	60	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	Preferred Generic, 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	0	0				0	0	0				0		0
H9306	009	2	1	01	01	H9306_009_2	7			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	25	25	25				25	25	25				25		25
H9306	009	2	1	01	01	H9306_009_2	7			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	25	25	25				25	25	25				25		25
H9306	009	2	1	01	01	H9306_009_2	7			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																														
H9314	001	0	1	01	01	H9314_001_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9314	001	0	1	01	01	H9314_001_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9314	001	0	1	01	01	H9314_001_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				69.92	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	22	22	22				22	22	22				22		22
H9314	001	0	1	01	01	H9314_001_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				33.32	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9314	001	0	1	01	01	H9314_001_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				488.34	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9326	001	0	1	04	01	H9326_001_0	8			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								9.00	18.00	27.00					4.00	8.00	12.00					4.00	8.00	0.00																4.00				4.00			0.30	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9326	001	0	1	04	01	H9326_001_0	8			Generic	3	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					9.00	18.00	27.00					9.00	18.00	22.50																9.00				9.00			0.47	0.30	0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9326	001	0	1	04	01	H9326_001_0	8			Preferred Brand	3	10	1	1	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											47.12	20	20	20				47.12	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	20	20	20	20	20	20	20	20	20				20		20
H9326	001	0	1	04	01	H9326_001_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											63.31	35	35	35				63.31	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	25	25	25	25	25	25	25	25	25				25		25
H9326	001	0	1	04	01	H9326_001_0	8			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											974.61	25						974.61	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H9326	002	0	1	04	01	H9326_002_0	8			Preferred Generic	3	01	1	2	1	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31								9.00	18.00	27.00					4.00	8.00	12.00					4.00	8.00	0.00																4.00				4.00			0.30	0.13	0.13			0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9326	002	0	1	04	01	H9326_002_0	8			Generic	3	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					9.00	18.00	27.00					9.00	18.00	22.50																9.00				9.00			0.47	0.30	0.30			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9326	002	0	1	04	01	H9326_002_0	8			Preferred Brand	3	10	1	1	3	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											45.12	20	20	20				45.12	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	20	20	20	20	20	20	20	20	20				20		20
H9326	002	0	1	04	01	H9326_002_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	100	1	2	30	60	100				30		31											62.54	35	35	35				62.54	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	25	25	25	25	25	25	25	25	25				25		25
H9326	002	0	1	04	01	H9326_002_0	8			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											971.65	25						971.65	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
H9364	001	0	1	02	01	H9364_001_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9364	001	0	1	02	01	H9364_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9364	001	0	1	02	01	H9364_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											125.91	25	25	25				125.91	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	001	0	1	02	01	H9364_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											64.14	36	36	36				62.36	35	35	35											36	36					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	001	0	1	02	01	H9364_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	001	0	1	02	01	H9364_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	002	0	1	02	01	H9364_002_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	002	0	1	02	01	H9364_002_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	002	0	1	02	01	H9364_002_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.59	20	20	20				83.59	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9364	002	0	1	02	01	H9364_002_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	002	0	1	02	01	H9364_002_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	002	0	1	02	01	H9364_002_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	003	0	1	02	01	H9364_003_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	003	0	1	02	01	H9364_003_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	003	0	1	02	01	H9364_003_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											85.13	20	20	20				85.13	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9364	003	0	1	02	01	H9364_003_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	003	0	1	02	01	H9364_003_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	003	0	1	02	01	H9364_003_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9364	004	0	1	02	01	H9364_004_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9364	004	0	1	02	01	H9364_004_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											112.17	25	25	25				112.17	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	004	0	1	02	01	H9364_004_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											64.58	50	50	50				64.58	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9364	004	0	1	02	01	H9364_004_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9364	004	0	1	02	01	H9364_004_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9387	001	0	1	04	01	H9387_001_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9387	001	0	1	04	01	H9387_001_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											115.65	25	25	25				115.65	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9387	001	0	1	04	01	H9387_001_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											74.28	34	34	34				72.10	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9387	001	0	1	04	01	H9387_001_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9387	001	0	1	04	01	H9387_001_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9387	004	0	1	04	01	H9387_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											100.96	25	25	25				100.96	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9387	004	0	1	04	01	H9387_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9387	004	0	1	04	01	H9387_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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											68.31	24	24	24				86.77	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											36.32	25	25	25				44.31	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											496.66	25						582.88	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	25			25			25			25			25		25
H9460	001	0	1	01	01	H9460_001_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9460	001	0	1	01	01	H9460_001_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9460	001	0	1	01	01	H9460_001_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9460	001	0	1	01	01	H9460_001_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											54.93	50	50	50				60.47	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9460	001	0	1	01	01	H9460_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											761.03	30						620.50	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	25			25			25			25			25		25
H9460	003	0	1	01	01	H9460_003_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9460	003	0	1	01	01	H9460_003_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9460	003	0	1	01	01	H9460_003_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9460	003	0	1	01	01	H9460_003_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											60.71	50	50	50				51.89	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9460	003	0	1	01	01	H9460_003_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											757.39	33						618.53	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	25			25			25			25			25		25
H9485	001	0	1	04	01	H9485_001_0	5			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	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																			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	5			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	25	25	25				25	25	25				25		25
H9485	001	0	1	04	01	H9485_001_0	5			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				98.08	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	25	25	25				25	25	25				25		25
H9485	001	0	1	04	01	H9485_001_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1038.05	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9485	002	0	1	04	01	H9485_002_0	5			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	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																			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	5			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	25	25	25				25	25	25				25		25
H9485	002	0	1	04	01	H9485_002_0	5			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				96.72	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	25	25	25				25	25	25				25		25
H9485	002	0	1	04	01	H9485_002_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1057.70	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9485	003	0	1	04	01	H9485_003_0	5			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	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																			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	5			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	25	25	25				25	25	25				25		25
H9485	003	0	1	04	01	H9485_003_0	5			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				87.41	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	25	25	25				25	25	25				25		25
H9485	003	0	1	04	01	H9485_003_0	5			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1248.13	29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9525	003	0	1	01	01	H9525_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		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																														
H9525	003	0	1	01	01	H9525_003_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	003	0	1	01	01	H9525_003_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9525	003	0	1	01	01	H9525_003_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		34				30.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9525	003	0	1	01	01	H9525_003_0	5		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																														
H9525	003	0	1	01	01	H9525_003_0	5		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																														
H9525	004	0	1	02	01	H9525_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			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	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	004	0	1	02	01	H9525_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											54.00	25	25	25				85.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	004	0	1	02	01	H9525_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											27.00	30	30	30				21.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	004	0	1	02	01	H9525_004_0	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	004	0	1	02	01	H9525_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			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	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	006	0	1	02	01	H9525_006_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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	006	0	1	02	01	H9525_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											58.00	25	25	25				80.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	006	0	1	02	01	H9525_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											30.00	30	30	30				21.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	006	0	1	02	01	H9525_006_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												29							29						29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	006	0	1	02	01	H9525_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																														
H9525	011	0	1	02	01	H9525_011_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																														
H9525	011	0	1	02	01	H9525_011_0	5			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					0.00	0.00	0.00					0.00	0.00	0.00																7.00				7.00			0.23	0.00	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	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											41.00	25	25	25				58.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	30.00	60.00	90.00	30.00	60.00	90.00	30.00	60.00	60.00				30.00		30.00	25	25	25	25	25	25	25	25	25				25		25
H9525	011	0	1	02	01	H9525_011_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											33.00	30	30	30				18.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	011	0	1	02	01	H9525_011_0	5			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																														
H9525	011	0	1	02	01	H9525_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		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				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	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	1	1	02	01	H9525_013_1	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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	1	1	02	01	H9525_013_1	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	013	1	1	02	01	H9525_013_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											21.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	013	1	1	02	01	H9525_013_1	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	1	1	02	01	H9525_013_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																														
H9525	013	2	1	02	01	H9525_013_2	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																														
H9525	013	2	1	02	01	H9525_013_2	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	2	1	02	01	H9525_013_2	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	013	2	1	02	01	H9525_013_2	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											21.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	013	2	1	02	01	H9525_013_2	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	2	1	02	01	H9525_013_2	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																														
H9525	013	3	1	02	01	H9525_013_3	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																														
H9525	013	3	1	02	01	H9525_013_3	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	3	1	02	01	H9525_013_3	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	013	3	1	02	01	H9525_013_3	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											21.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	013	3	1	02	01	H9525_013_3	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	3	1	02	01	H9525_013_3	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																														
H9525	013	4	1	02	01	H9525_013_4	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																														
H9525	013	4	1	02	01	H9525_013_4	5			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								10.00	20.00	30.00					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	4	1	02	01	H9525_013_4	5			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	013	4	1	02	01	H9525_013_4	5			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											21.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	013	4	1	02	01	H9525_013_4	5			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	4	1	02	01	H9525_013_4	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																														
H9525	013	5	1	02	01	H9525_013_5	6			Preferred Generic	4	01	1	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		34								0.00	0.00	0.00					0.00	0.00	0.00					0.00	0.00	0.00																0.00				0.00			0.00	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	5	1	02	01	H9525_013_5	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					0.00	0.00	0.00					0.00	0.00	0.00																10.00				10.00			0.33	0.00	0.00			0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	5	1	02	01	H9525_013_5	6			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											47.00	25	25	25				74.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
H9525	013	5	1	02	01	H9525_013_5	6			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34											21.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
H9525	013	5	1	02	01	H9525_013_5	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	013	5	1	02	01	H9525_013_5	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																														
H9525	018	0	1	01	01	H9525_018_0	5		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																														
H9525	018	0	1	01	01	H9525_018_0	5		N	Generic	4	11	1	1	2	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				3.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	018	0	1	01	01	H9525_018_0	5		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				2	2	30	60	90				30		34				67.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9525	018	0	1	01	01	H9525_018_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		34				29.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9525	018	0	1	01	01	H9525_018_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		34					26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9525	018	0	1	01	01	H9525_018_0	5		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																														
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											15.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											15.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											15.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											15.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											15.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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											45.00	25		25				43.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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								16.00		48.00					11.00		0.00											16.00		48.00				11.00		0.00				16.00				16.00			0.52	0.35		0.52	0.35	0.52	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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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	25		25				40.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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								16.00		48.00					11.00		0.00											16.00		48.00				11.00		0.00				16.00				16.00			0.52	0.35		0.52	0.35	0.52	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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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	25		25				40.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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								16.00		48.00					11.00		0.00											16.00		48.00				11.00		0.00				16.00				16.00			0.52	0.35		0.52	0.35	0.52	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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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	25		25				40.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
H9572	002	4	1	04	01	H9572_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																														
H9572	002	4	1	04	01	H9572_002_4	7			Generic	4	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								16.00		48.00					11.00		0.00											16.00		48.00				11.00		0.00				16.00				16.00			0.52	0.35		0.52	0.35	0.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9572	002	4	1	04	01	H9572_002_4	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
H9572	002	4	1	04	01	H9572_002_4	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											44.00	25		25				40.00	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	25		25	25		25	25		25	25		25	25		25
H9572	002	4	1	04	01	H9572_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	25			25			25			25			25		25
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								16.00		48.00					11.00		0.00											16.00		48.00				11.00		0.00				16.00				16.00			0.52	0.35		0.52	0.35	0.52	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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				18.00	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	20		20	20		20	20		20	20		20	20		20
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	25		25				40.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
H9572	003	1	1	04	01	H9572_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																														
H9572	003	1	1	04	01	H9572_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																														
H9572	003	1	1	04	01	H9572_003_1	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				19.00	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	20		20	20		20	20		20	20		20	20		20
H9572	003	1	1	04	01	H9572_003_1	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											45.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	003	1	1	04	01	H9572_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	25			25			25			25			25		25
H9572	003	2	1	04	01	H9572_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																														
H9572	003	2	1	04	01	H9572_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																														
H9572	003	2	1	04	01	H9572_003_2	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				19.00	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	20		20	20		20	20		20	20		20	20		20
H9572	003	2	1	04	01	H9572_003_2	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											45.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	003	2	1	04	01	H9572_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	25			25			25			25			25		25
H9572	003	3	1	04	01	H9572_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																														
H9572	003	3	1	04	01	H9572_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																														
H9572	003	3	1	04	01	H9572_003_3	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				19.00	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	20		20	20		20	20		20	20		20	20		20
H9572	003	3	1	04	01	H9572_003_3	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											45.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	003	3	1	04	01	H9572_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	25			25			25			25			25		25
H9572	003	4	1	04	01	H9572_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																														
H9572	003	4	1	04	01	H9572_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																														
H9572	003	4	1	04	01	H9572_003_4	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				19.00	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	20		20	20		20	20		20	20		20	20		20
H9572	003	4	1	04	01	H9572_003_4	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											45.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	003	4	1	04	01	H9572_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	25			25			25			25			25		25
H9572	003	6	1	04	01	H9572_003_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	003	6	1	04	01	H9572_003_6	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																														
H9572	003	6	1	04	01	H9572_003_6	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											16.00	20		20				19.00	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	20		20	20		20	20		20	20		20	20		20
H9572	003	6	1	04	01	H9572_003_6	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											45.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	003	6	1	04	01	H9572_003_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	25			25			25			25			25		25
H9572	004	1	1	04	01	H9572_004_1	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																														
H9572	004	1	1	04	01	H9572_004_1	9			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																														
H9572	004	1	1	04	01	H9572_004_1	9			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											26.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H9572	004	1	1	04	01	H9572_004_1	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	004	1	1	04	01	H9572_004_1	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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																														
H9572	004	2	1	04	01	H9572_004_2	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											26.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
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											48.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	004	4	1	04	01	H9572_004_4	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																														
H9572	004	4	1	04	01	H9572_004_4	9			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																														
H9572	004	4	1	04	01	H9572_004_4	9			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											26.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H9572	004	4	1	04	01	H9572_004_4	9			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											48.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
H9572	004	4	1	04	01	H9572_004_4	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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																														
H9572	004	6	1	04	01	H9572_004_6	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											26.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
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											48.00	25		25				44.00	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	25		25	25		25	25		25	25		25	25		25
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	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	007	1	1	04	01	H9572_007_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	007	1	1	04	01	H9572_007_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	007	1	1	04	01	H9572_007_1	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											29.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
H9572	007	1	1	04	01	H9572_007_1	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											62.00	30		30				55.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	007	1	1	04	01	H9572_007_1	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	007	2	1	04	01	H9572_007_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	007	2	1	04	01	H9572_007_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	007	2	1	04	01	H9572_007_2	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											29.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
H9572	007	2	1	04	01	H9572_007_2	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											62.00	30		30				55.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	007	2	1	04	01	H9572_007_2	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	007	3	1	04	01	H9572_007_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	007	3	1	04	01	H9572_007_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	007	3	1	04	01	H9572_007_3	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											29.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
H9572	007	3	1	04	01	H9572_007_3	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											62.00	30		30				55.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	007	3	1	04	01	H9572_007_3	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	007	4	1	04	01	H9572_007_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	007	4	1	04	01	H9572_007_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	007	4	1	04	01	H9572_007_4	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											29.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
H9572	007	4	1	04	01	H9572_007_4	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											62.00	30		30				55.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	007	4	1	04	01	H9572_007_4	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	007	6	1	04	01	H9572_007_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	007	6	1	04	01	H9572_007_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	007	6	1	04	01	H9572_007_6	8			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											29.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
H9572	007	6	1	04	01	H9572_007_6	8			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											62.00	30		30				55.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	007	6	1	04	01	H9572_007_6	8			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	008	0	1	04	01	H9572_008_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																														
H9572	008	0	1	04	01	H9572_008_0	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																														
H9572	008	0	1	04	01	H9572_008_0	7			Preferred Brand	4	10	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											27.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H9572	008	0	1	04	01	H9572_008_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				53.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	008	0	1	04	01	H9572_008_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	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	25			25			25			25			25		25
H9572	009	0	1	04	01	H9572_009_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																														
H9572	009	0	1	04	01	H9572_009_0	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																														
H9572	009	0	1	04	01	H9572_009_0	7			Preferred Brand	4	11	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											27.00	20		20				29.00	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	20		20	20		20	20		20	20		20	20		20
H9572	009	0	1	04	01	H9572_009_0	7			Non-Preferred Drug	4	11	1	1	4	1		110	01		110	1				31		90	1	2				31		90	31		31											58.00	30		30				53.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	009	0	1	04	01	H9572_009_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				31								31			31		31											1.00	31						1.00	31												31						31					31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9572	010	0	1	04	01	H9572_010_0	7			Preferred Generic	3	01	1	2	1	1		110	01		110	1				31		90	1	2				31		90	31		31								7.00		21.00					2.00		6.00											7.00		21.00				2.00		6.00				7.00				7.00			0.23	0.06		0.23	0.06	0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9572	010	0	1	04	01	H9572_010_0	7			Generic	3	01	1	2	2	1		110	01		110	1				31		90	1	2				31		90	31		31								20.00		60.00					15.00		45.00											20.00		60.00				15.00		45.00				20.00				20.00			0.65	0.48		0.65	0.48	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9572	010	0	1	04	01	H9572_010_0	7			Preferred Brand	3	10	1	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											35.00	20		20				37.00	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	20		20	20		20	20		20	20		20	20		20
H9572	010	0	1	04	01	H9572_010_0	7			Non-Preferred Drug	3	11	1	1	4	1		110	01		110	1				31		90	1	2				30		90	31		31											64.00	31		31				60.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
H9572	010	0	1	04	01	H9572_010_0	7			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	25			25			25			25			25		25
H9589	003	0	1	04	01	H9589_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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				5.00				5.00			0.17	0.00		0.17	0.00	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9589	003	0	1	04	01	H9589_003_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					5.00	10.00	15.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.17		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9589	003	0	1	04	01	H9589_003_0	7			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											61.96	20	20	20				61.96	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	20	20	20	20	20	20	20	20	20	20	20	20	20		20
H9589	003	0	1	04	01	H9589_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											84.40	30	30	30				84.40	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	30.00	60.00	90.00	35.00	70.00	105.00	30.00	60.00	90.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9589	003	0	1	04	01	H9589_003_0	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											1158.83	28						1158.83	28												28						28					28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00			30.00			35.00			30.00			35.00		35.00	25			25			25			25			25		25
H9589	003	0	1	04	01	H9589_003_0	7			Select Care Drugs	4	01	1	2	6	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00											0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00			0.00	0.00		0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9615	021	0	1	04	01	H9615_021_0	16			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H9615	021	0	1	04	01	H9615_021_0	16			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H9615	021	0	1	04	01	H9615_021_0	16			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				38.09	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H9615	021	0	1	04	01	H9615_021_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				93.17	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	25		25				25		25				25		25
H9615	021	0	1	04	01	H9615_021_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1255.39	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9615	022	0	1	04	01	H9615_022_0	16			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H9615	022	0	1	04	01	H9615_022_0	16			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H9615	022	0	1	04	01	H9615_022_0	16			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				42.98	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H9615	022	0	1	04	01	H9615_022_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				121.86	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	25		25				25		25				25		25
H9615	022	0	1	04	01	H9615_022_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1070.69	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9615	023	0	1	04	01	H9615_023_0	16			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H9615	023	0	1	04	01	H9615_023_0	16			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H9615	023	0	1	04	01	H9615_023_0	16			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				38.59	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H9615	023	0	1	04	01	H9615_023_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				106.68	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	25		25				25		25				25		25
H9615	023	0	1	04	01	H9615_023_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				869.03	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9615	024	0	1	04	01	H9615_024_0	16			Preferred Generic	4	01	1	2	1	1	110		01	110		1	30		100				2	2	30		100				30		31	0.00		0.00																			0.00		0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00				0.00		0.00	0		0				0		0				0		0
H9615	024	0	1	04	01	H9615_024_0	16			Generic	4	01	1	2	2	1	110		01	110		1	30		90				2	2	30		90				30		31	2.00		6.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
H9615	024	0	1	04	01	H9615_024_0	16			Preferred Brand	4	11	1	1	3	1	110		01	110		1	30		90				2	2	30		90				30		31				38.44	16		16																		16		16															16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00				35.00		70.00				35.00		35.00	16		16				16		16				16		16
H9615	024	0	1	04	01	H9615_024_0	16			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		90				2	2	30		90				30		31				101.36	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	25		25				25		25				25		25
H9615	024	0	1	04	01	H9615_024_0	16			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				957.04	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9630	002	0	1	02	01	H9630_002_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9630	002	0	1	02	01	H9630_002_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9630	002	0	1	02	01	H9630_002_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											128.85	25	25	25				128.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	002	0	1	02	01	H9630_002_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											50.62	37	37	37				49.25	36	36	36											37	37					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	002	0	1	02	01	H9630_002_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	002	0	1	02	01	H9630_002_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9630	008	0	1	02	01	H9630_008_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9630	008	0	1	02	01	H9630_008_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											123.25	25	25	25				123.25	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	008	0	1	02	01	H9630_008_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											55.49	49	49	49				54.36	48	48	48											49	49					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	008	0	1	02	01	H9630_008_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	008	0	1	02	01	H9630_008_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	010	0	1	02	01	H9630_010_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								12.00	24.00	36.00					0.00	0.00	0.00												24.00	36.00					0.00	0.00				12.00				12.00			0.40	0.00				0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	010	0	1	02	01	H9630_010_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	010	0	1	02	01	H9630_010_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.62	20	20	20				91.62	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9630	010	0	1	02	01	H9630_010_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	010	0	1	02	01	H9630_010_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	010	0	1	02	01	H9630_010_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	011	0	1	02	01	H9630_011_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	011	0	1	02	01	H9630_011_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	011	0	1	02	01	H9630_011_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											93.42	20	20	20				93.42	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9630	011	0	1	02	01	H9630_011_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	011	0	1	02	01	H9630_011_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	011	0	1	02	01	H9630_011_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	014	0	1	02	01	H9630_014_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	014	0	1	02	01	H9630_014_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	014	0	1	02	01	H9630_014_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											94.10	21	21	21				94.10	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		70.00	105.00		70.00	105.00	35.00		35.00	21	21	21	21	21	21		21	21		21	21	21		21
H9630	014	0	1	02	01	H9630_014_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9630	014	0	1	02	01	H9630_014_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9630	014	0	1	02	01	H9630_014_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9678	002	0	1	04	01	H9678_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	1.00	2.00	2.50																			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, Select Care Drugs	1.00	2.00	2.50				1.00	2.00	2.50				1.00		1.00	25	25	25				25	25	25				25		25
H9678	002	0	1	04	01	H9678_002_0	7			Generic	4	11	3	2	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	2.00	4.00	5.00																			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, Select Care Drugs	2.00	4.00	5.00				2.00	4.00	5.00				2.00		2.00	25	25	25				25	25	25				25		25
H9678	002	0	1	04	01	H9678_002_0	7			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				44.92	18	18	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				35.00	70.00	105.00				35.00		35.00	18	18	18				18	18	18				18		18
H9678	002	0	1	04	01	H9678_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				31.83	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9678	002	0	1	04	01	H9678_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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9678	002	0	1	04	01	H9678_002_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, 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	0	0				0	0	0				0		0
H9686	004	0	1	01	01	H9686_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	004	0	1	01	01	H9686_004_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	004	0	1	01	01	H9686_004_0	7			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	25	25	25				25	25	25				25		25
H9686	004	0	1	01	01	H9686_004_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	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	25	25	25				25	25	25				25		25
H9686	004	0	1	01	01	H9686_004_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				575.88	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	7			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	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
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				5.78	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		35.00	25	25	25				25	25	25				25		25
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				65.28	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
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				35.06	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		35.00	25	25	25				25	25	25				25		25
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				436.06	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	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	006	0	1	01	01	H9686_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	006	0	1	01	01	H9686_006_0	7			Generic	4	11	1	1	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				5.23	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	25	25	25				25	25	25				25		25
H9686	006	0	1	01	01	H9686_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				78.70	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		35.00	25	25	25				25	25	25				25		25
H9686	006	0	1	01	01	H9686_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				48.36	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		35.00	25	25	25				25	25	25				25		25
H9686	006	0	1	01	01	H9686_006_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				527.31	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	006	0	1	01	01	H9686_006_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	007	0	1	01	01	H9686_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	25	25	25				25	25	25				25		25
H9686	007	0	1	01	01	H9686_007_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	007	0	1	01	01	H9686_007_0	7			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	25	25	25				25	25	25				25		25
H9686	007	0	1	01	01	H9686_007_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.64	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		35.00	25	25	25				25	25	25				25		25
H9686	007	0	1	01	01	H9686_007_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				599.17	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	007	0	1	01	01	H9686_007_0	7			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	008	0	1	01	01	H9686_008_0	10			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	008	0	1	01	01	H9686_008_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	25	25	25				25	25	25				25		25
H9686	008	0	1	01	01	H9686_008_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	25	25	25				25	25	25				25		25
H9686	008	0	1	01	01	H9686_008_0	10			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				49.12	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		35.00	25	25	25				25	25	25				25		25
H9686	008	0	1	01	01	H9686_008_0	10			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				448.41	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	008	0	1	01	01	H9686_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	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	009	0	1	01	01	H9686_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, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	009	0	1	01	01	H9686_009_0	7			Generic	4	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	25	25	25				25	25	25				25		25
H9686	009	0	1	01	01	H9686_009_0	7			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	25	25	25				25	25	25				25		25
H9686	009	0	1	01	01	H9686_009_0	7			Non-Preferred Drug	4	11	3	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				52.68	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		35.00	25	25	25				25	25	25				25		25
H9686	009	0	1	01	01	H9686_009_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				599.44	33																				33																	33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9686	009	0	1	01	01	H9686_009_0	7			Select Care Drugs	4	01	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		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																														
H9699	007	0	1	01	01	H9699_007_0	5			Preferred Generic	4	11	1	2	1	1	110		01			1	30		100				1	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																														
H9699	007	0	1	01	01	H9699_007_0	5			Generic	4	11	1	2	2	1	110		01			1	30		100				1	2							30		31	5.00		12.50																																					5.00				5.00		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	1	3	1	110		01			1	30		100				1	2							30		31				27.10	17		17																																			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	17		17										17		17
H9699	007	0	1	01	01	H9699_007_0	5			Non-Preferred Drug	4	11	1	1	4	1	110		01			1	30		100				1	2							30		31				68.81	34		34																																			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
H9699	007	0	1	01	01	H9699_007_0	5			Specialty Tier	4	11	1	1	5	1	010		01			1	30														30		31				584.40	27																																					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
H9700	001	0	1	04	01	H9700_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	0	0	0				0	0	0				0		0
H9700	001	0	1	04	01	H9700_001_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	0	0	0				0	0	0				0		0
H9700	001	0	1	04	01	H9700_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				33.00	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	19	19	19				19	19	19				19		19
H9700	001	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	001	0	1	04	01	H9700_001_0	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	25						25						25		25
H9700	002	0	1	04	01	H9700_002_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	0	0	0				0	0	0				0		0
H9700	002	0	1	04	01	H9700_002_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	25	25	25				25	25	25				25		25
H9700	002	0	1	04	01	H9700_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				39.00	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	21	21	21				21	21	21				21		21
H9700	002	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	002	0	1	04	01	H9700_002_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	25						25						25		25
H9700	003	0	1	04	01	H9700_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	0	0	0				0	0	0				0		0
H9700	003	0	1	04	01	H9700_003_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	0	0	0				0	0	0				0		0
H9700	003	0	1	04	01	H9700_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				33.00	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	19	19	19				19	19	19				19		19
H9700	003	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	003	0	1	04	01	H9700_003_0	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	25						25						25		25
H9700	004	0	1	04	01	H9700_004_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9700	004	0	1	04	01	H9700_004_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	25	25	25				25	25	25				25		25
H9700	004	0	1	04	01	H9700_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				39.00	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	21	21	21				21	21	21				21		21
H9700	004	0	1	04	01	H9700_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				65.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9700	004	0	1	04	01	H9700_004_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	25						25						25		25
H9700	005	0	1	04	01	H9700_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9700	005	0	1	04	01	H9700_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9700	005	0	1	04	01	H9700_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				33.00	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	19	19	19				19	19	19				19		19
H9700	005	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	005	0	1	04	01	H9700_005_0	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	25						25						25		25
H9700	006	0	1	04	01	H9700_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	0	0	0				0	0	0				0		0
H9700	006	0	1	04	01	H9700_006_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	25	25	25				25	25	25				25		25
H9700	006	0	1	04	01	H9700_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				39.00	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	21	21	21				21	21	21				21		21
H9700	006	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	006	0	1	04	01	H9700_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	25						25						25		25
H9700	008	0	1	04	01	H9700_008_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	0	0	0				0	0	0				0		0
H9700	008	0	1	04	01	H9700_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9700	008	0	1	04	01	H9700_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				32.00	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	19	19	19				19	19	19				19		19
H9700	008	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	008	0	1	04	01	H9700_008_0	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	25						25						25		25
H9700	009	0	1	04	01	H9700_009_0	5			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9700	009	0	1	04	01	H9700_009_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	25	25	25				25	25	25				25		25
H9700	009	0	1	04	01	H9700_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				39.00	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	21	21	21				21	21	21				21		21
H9700	009	0	1	04	01	H9700_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				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	25	25	25				25	25	25				25		25
H9700	009	0	1	04	01	H9700_009_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	25						25						25		25
H9706	001	0	1	01	01	H9706_001_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	001	0	1	01	01	H9706_001_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	001	0	1	01	01	H9706_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											53.63	20	20	20				49.78	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	70.00	35.00	70.00	70.00	35.00		35.00	20	20	20	17	17	17	20	20	20	17	17	17	20		20
H9706	001	0	1	01	01	H9706_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											86.66	43	43	43				78.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	001	0	1	01	01	H9706_001_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											602.42	27						560.57	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9706	005	0	1	01	01	H9706_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								5.00	10.00	15.00					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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	005	0	1	01	01	H9706_005_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	005	0	1	01	01	H9706_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											48.75	22	22	22				41.27	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	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22	18	18	18	22	22	22	18	18	18	22		22
H9706	005	0	1	01	01	H9706_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											84.12	41	41	41				83.06	38	38	38										41	41	41				38	38	38			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	005	0	1	01	01	H9706_005_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											709.13	27						668.47	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9706	007	0	1	01	01	H9706_007_0	4			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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	007	0	1	01	01	H9706_007_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					1.00	2.00	3.00											6.00	12.00	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	007	0	1	01	01	H9706_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											51.77	21	21	21				41.32	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	17	17	17	21	21	21	17	17	17	21		21
H9706	007	0	1	01	01	H9706_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											79.29	36	36	36				82.37	33	33	33										36	36	36				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	007	0	1	01	01	H9706_007_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											679.90	25						568.88	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9706	008	0	1	01	01	H9706_008_0	6			Preferred Generic	4	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	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	008	0	1	01	01	H9706_008_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	008	0	1	01	01	H9706_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											42.58	21	21	21				40.32	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	70.00	35.00	70.00	70.00	35.00		35.00	21	21	21	18	18	18	21	21	21	18	18	18	21		21
H9706	008	0	1	01	01	H9706_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											79.40	42	42	42				85.81	39	39	39										42	42	42				39	39	39			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	008	0	1	01	01	H9706_008_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											846.96	27						665.10	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9706	009	0	1	01	01	H9706_009_0	6			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	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	15.00	0.00	0.00	0.00	5.00	10.00	10.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	009	0	1	01	01	H9706_009_0	6			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	12.00				1.00	2.00	2.00				6.00				6.00			0.20	0.03		0.20	0.03	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00	1.00	2.00	3.00	6.00	12.00	12.00	1.00	2.00	2.00	6.00		6.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	009	0	1	01	01	H9706_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											52.09	22	22	22				42.79	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	70.00	35.00	70.00	70.00	35.00		35.00	22	22	22	18	18	18	22	22	22	18	18	18	22		22
H9706	009	0	1	01	01	H9706_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											78.44	39	39	39				85.35	37	37	37										39	39	39				37	37	37			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9706	009	0	1	01	01	H9706_009_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											820.48	27						699.11	27												27						27					27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9725	003	0	1	01	01	H9725_003_0	6		N	Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	003	0	1	01	01	H9725_003_0	6		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	003	0	1	01	01	H9725_003_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											21.11	24	24	24				23.80	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
H9725	003	0	1	01	01	H9725_003_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											50.83	25	25	25				54.67	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	003	0	1	01	01	H9725_003_0	6		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											490.70	25						408.50	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	25			25			25			25			25		25
H9725	009	1	1	01	01	H9725_009_1	7			Preferred Generic	4	01	3	2	1	1		111	01		111	1				30	60	100	1	2				30	60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00											10.00	20.00	30.00				0.00	0.00	0.00				10.00				10.00			0.33	0.00		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	0.00	0.00	0.00	10.00	20.00	30.00	0.00	0.00	0.00	10.00		10.00	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	009	1	1	01	01	H9725_009_1	7			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	009	1	1	01	01	H9725_009_1	7			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								47.00	94.00	141.00					47.00	94.00	141.00											47.00	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	1	1	01	01	H9725_009_1	7			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											57.08	50	50	50				59.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	1	1	01	01	H9725_009_1	7			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											473.42	29						585.28	29												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	25			25			25			25			25		25
H9725	009	2	1	01	01	H9725_009_2	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	009	2	1	01	01	H9725_009_2	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	009	2	1	01	01	H9725_009_2	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	2	1	01	01	H9725_009_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											57.08	50	50	50				59.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	2	1	01	01	H9725_009_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											473.42	29						585.28	29												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	25			25			25			25			25		25
H9725	009	3	1	01	01	H9725_009_3	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	009	3	1	01	01	H9725_009_3	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	009	3	1	01	01	H9725_009_3	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	3	1	01	01	H9725_009_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											57.08	50	50	50				59.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	3	1	01	01	H9725_009_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											473.42	29						585.28	29												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	25			25			25			25			25		25
H9725	009	4	1	01	01	H9725_009_4	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	009	4	1	01	01	H9725_009_4	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	009	4	1	01	01	H9725_009_4	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	4	1	01	01	H9725_009_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											57.08	50	50	50				59.17	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	009	4	1	01	01	H9725_009_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											473.42	29						585.28	29												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	25			25			25			25			25		25
H9725	013	0	1	01	01	H9725_013_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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	013	0	1	01	01	H9725_013_0	6		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	40.00	60.00				20.00	40.00	0.00				20.00				20.00			0.67	0.67		0.67	0.67	0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	60.00	20.00	40.00	0.00	20.00		20.00	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	013	0	1	01	01	H9725_013_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											20.20	23	23	23				22.05	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	23	23	23	23	23	23	23	23	23	23	23	23	23		23
H9725	013	0	1	01	01	H9725_013_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											47.54	25	25	25				50.87	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	013	0	1	01	01	H9725_013_0	6		N	Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											454.00	25						417.31	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	25			25			25			25			25		25
H9725	014	0	1	01	01	H9725_014_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	014	0	1	01	01	H9725_014_0	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	014	0	1	01	01	H9725_014_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	014	0	1	01	01	H9725_014_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											55.78	50	50	50				59.84	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	014	0	1	01	01	H9725_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											557.63	29						536.41	29												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	25			25			25			25			25		25
H9725	015	1	1	01	01	H9725_015_1	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	015	1	1	01	01	H9725_015_1	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	015	1	1	01	01	H9725_015_1	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	1	1	01	01	H9725_015_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											44.73	50	50	50				52.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	1	1	01	01	H9725_015_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											524.41	33						675.75	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	25			25			25			25			25		25
H9725	015	2	1	01	01	H9725_015_2	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	015	2	1	01	01	H9725_015_2	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	015	2	1	01	01	H9725_015_2	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	2	1	01	01	H9725_015_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											44.73	50	50	50				52.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	2	1	01	01	H9725_015_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											524.41	33						675.75	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	25			25			25			25			25		25
H9725	015	3	1	01	01	H9725_015_3	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	015	3	1	01	01	H9725_015_3	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	015	3	1	01	01	H9725_015_3	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	3	1	01	01	H9725_015_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											44.73	50	50	50				52.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	3	1	01	01	H9725_015_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											524.41	33						675.75	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	25			25			25			25			25		25
H9725	015	4	1	01	01	H9725_015_4	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	015	4	1	01	01	H9725_015_4	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	015	4	1	01	01	H9725_015_4	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	4	1	01	01	H9725_015_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											44.73	50	50	50				52.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	015	4	1	01	01	H9725_015_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											524.41	33						675.75	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	25			25			25			25			25		25
H9725	016	0	1	01	01	H9725_016_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	016	0	1	01	01	H9725_016_0	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	016	0	1	01	01	H9725_016_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	016	0	1	01	01	H9725_016_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											53.56	50	50	50				48.88	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	016	0	1	01	01	H9725_016_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											618.64	33						599.56	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	25			25			25			25			25		25
H9725	017	1	1	01	01	H9725_017_1	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	017	1	1	01	01	H9725_017_1	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	017	1	1	01	01	H9725_017_1	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	1	1	01	01	H9725_017_1	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											62.60	50	50	50				59.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	1	1	01	01	H9725_017_1	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											503.53	30						583.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9725	017	2	1	01	01	H9725_017_2	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	017	2	1	01	01	H9725_017_2	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	017	2	1	01	01	H9725_017_2	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	2	1	01	01	H9725_017_2	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											62.60	50	50	50				59.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	2	1	01	01	H9725_017_2	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											503.53	30						583.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9725	017	3	1	01	01	H9725_017_3	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	017	3	1	01	01	H9725_017_3	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	017	3	1	01	01	H9725_017_3	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	3	1	01	01	H9725_017_3	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											62.60	50	50	50				59.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	3	1	01	01	H9725_017_3	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											503.53	30						583.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9725	017	4	1	01	01	H9725_017_4	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	017	4	1	01	01	H9725_017_4	6			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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	017	4	1	01	01	H9725_017_4	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	4	1	01	01	H9725_017_4	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											62.60	50	50	50				59.39	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	017	4	1	01	01	H9725_017_4	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											503.53	30						583.88	30												30						30					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
H9725	018	0	1	02	01	H9725_018_0	6			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
H9725	018	0	1	02	01	H9725_018_0	6			Generic	4	01	1	2	2	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31								20.00	40.00	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	25	25	25	25	25	25	25	25	25	25	25	0	25		25
H9725	018	0	1	02	01	H9725_018_0	6			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	94.00	141.00				47.00	94.00	141.00				47.00				47.00			1.57	1.57		1.57	1.57	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	018	0	1	02	01	H9725_018_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	100	2	2				30	60	100	30		31											70.58	50	50	50				59.34	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
H9725	018	0	1	02	01	H9725_018_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											609.74	30						528.44	30												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	25			25			25			25			25		25
H9730	003	0	1	02	01	H9730_003_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	003	0	1	02	01	H9730_003_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	003	0	1	02	01	H9730_003_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											91.57	20	20	20				91.57	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9730	003	0	1	02	01	H9730_003_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	003	0	1	02	01	H9730_003_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	003	0	1	02	01	H9730_003_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	004	0	1	02	01	H9730_004_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	004	0	1	02	01	H9730_004_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	004	0	1	02	01	H9730_004_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											92.95	20	20	20				92.95	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9730	004	0	1	02	01	H9730_004_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	004	0	1	02	01	H9730_004_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	004	0	1	02	01	H9730_004_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	007	0	1	02	01	H9730_007_0	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9730	007	0	1	02	01	H9730_007_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9730	007	0	1	02	01	H9730_007_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											130.14	25	25	25				130.14	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	007	0	1	02	01	H9730_007_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											49.63	36	36	36				49.63	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	007	0	1	02	01	H9730_007_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	007	0	1	02	01	H9730_007_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	4	11	3	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					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																														
H9730	009	0	1	02	01	H9730_009_0	8			Generic	4	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					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																														
H9730	009	0	1	02	01	H9730_009_0	8			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											129.98	25	25	25				129.98	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	009	0	1	02	01	H9730_009_0	8			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											50.66	34	34	34				49.17	33	33	33											34	34					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	009	0	1	02	01	H9730_009_0	8			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	009	0	1	02	01	H9730_009_0	8			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				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	8			Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	010	0	1	02	01	H9730_010_0	8			Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			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	8			Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											83.20	20	20	20				83.20	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9730	010	0	1	02	01	H9730_010_0	8			Non-Preferred Drug	3	11	1	1	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31											36.66	32	32	32				36.66	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	010	0	1	02	01	H9730_010_0	8			Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												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	8			Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	011	0	1	02	01	H9730_011_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	011	0	1	02	01	H9730_011_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	011	0	1	02	01	H9730_011_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											89.45	20	20	20				89.45	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9730	011	0	1	02	01	H9730_011_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9730	011	0	1	02	01	H9730_011_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9730	011	0	1	02	01	H9730_011_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9771	001	0	1	01	01	H9771_001_0	2		N	Preferred Generic	4	11	1	2	1	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9771	001	0	1	01	01	H9771_001_0	2		N	Generic	4	01	1	2	2	1	111		10	111		1	30	60	100				1	2	30	60	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9771	001	0	1	01	01	H9771_001_0	2		N	Preferred Brand	4	11	1	1	3	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				70.25	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	22	22	22				22	22	22				22		22
H9771	001	0	1	01	01	H9771_001_0	2		N	Non-Preferred Drug	4	11	1	1	4	1	111		10	111		1	30	60	100				1	2	30	60	100					10	31				36.27	25	25	25																		25	25	25																25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9771	001	0	1	01	01	H9771_001_0	2		N	Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				516.84	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9802	001	0	1	04	01	H9802_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	0	0	0				0	0	0				0		0
H9802	001	0	1	04	01	H9802_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9802	001	0	1	04	01	H9802_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				32.00	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	19	19	19				19	19	19				19		19
H9802	001	0	1	04	01	H9802_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	001	0	1	04	01	H9802_001_0	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	25						25						25		25
H9802	002	0	1	04	01	H9802_002_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	0	0	0				0	0	0				0		0
H9802	002	0	1	04	01	H9802_002_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	25	25	25				25	25	25				25		25
H9802	002	0	1	04	01	H9802_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				39.00	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	21	21	21				21	21	21				21		21
H9802	002	0	1	04	01	H9802_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				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	25	25	25				25	25	25				25		25
H9802	002	0	1	04	01	H9802_002_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	25						25						25		25
H9802	004	0	1	04	01	H9802_004_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H9802	004	0	1	04	01	H9802_004_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	004	0	1	04	01	H9802_004_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				43.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	004	0	1	04	01	H9802_004_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				61.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	004	0	1	04	01	H9802_004_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9802	004	0	1	04	01	H9802_004_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9802	006	0	1	04	01	H9802_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9802	006	0	1	04	01	H9802_006_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9802	006	0	1	04	01	H9802_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	006	0	1	04	01	H9802_006_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H9802	006	0	1	04	01	H9802_006_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9802	006	0	1	04	01	H9802_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9802	008	0	1	04	01	H9802_008_0	6		N	Preferred Generic	4	11	1	1	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H9802	008	0	1	04	01	H9802_008_0	6		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	008	0	1	04	01	H9802_008_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				41.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	008	0	1	04	01	H9802_008_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9802	008	0	1	04	01	H9802_008_0	6		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9802	008	0	1	04	01	H9802_008_0	6		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9802	009	0	1	04	01	H9802_009_0	7			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9802	009	0	1	04	01	H9802_009_0	7			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9802	009	0	1	04	01	H9802_009_0	7			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				34.00	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		35.00	21	21	21				21	21	21				21		21
H9802	009	0	1	04	01	H9802_009_0	7			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9802	009	0	1	04	01	H9802_009_0	7			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9802	009	0	1	04	01	H9802_009_0	7			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9808	004	0	1	04	01	H9808_004_0	6			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	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																														
H9808	004	0	1	04	01	H9808_004_0	6			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	45.00					3.00	6.00	9.00					3.00	6.00	9.00																	15.00			15.00			0.50	0.10	0.10			0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9808	004	0	1	04	01	H9808_004_0	6			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											56.80	25	25	25				46.23	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	25	25	25	20	20	20	20	20	20				25		25
H9808	004	0	1	04	01	H9808_004_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											109.78	45	45	45				81.92	35	35	35				35	35	35																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	25	25	25	25	25	25	25	25	25				25		25
H9808	004	0	1	04	01	H9808_004_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31											454.40	30						434.21	30						30																		30		30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9808	005	0	1	04	01	H9808_005_0	6			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	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																														
H9808	005	0	1	04	01	H9808_005_0	6			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	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																														
H9808	005	0	1	04	01	H9808_005_0	6			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											54.44	25	25	25				42.77	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	25	25	25	20	20	20	20	20	20				25		25
H9808	005	0	1	04	01	H9808_005_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											92.17	45	45	45				75.34	35	35	35				35	35	35																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	25	25	25	25	25	25	25	25	25				25		25
H9808	005	0	1	04	01	H9808_005_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31											530.11	31						416.91	31						31																		31		31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9808	010	0	1	04	01	H9808_010_0	6			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	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																														
H9808	010	0	1	04	01	H9808_010_0	6			Generic	4	01	1	2	2	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31								17.00	34.00	51.00					3.00	6.00	9.00					3.00	6.00	9.00																	17.00			17.00			0.57	0.10	0.10			0.55	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9808	010	0	1	04	01	H9808_010_0	6			Preferred Brand	4	11	1	1	3	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											56.80	25	25	25				46.24	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	25	25	25	20	20	20	20	20	20				25		25
H9808	010	0	1	04	01	H9808_010_0	6			Non-Preferred Drug	4	11	1	1	4	1		111	10	111		1				30	60	100	1	2	30	60	100					29	31											109.01	45	45	45				81.68	35	35	35				35	35	35																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	25	25	25	25	25	25	25	25	25				25		25
H9808	010	0	1	04	01	H9808_010_0	6			Specialty Tier	4	11	1	1	5	1		010	10	010		1				30					30							29	31											441.28	29						422.43	29						29																		29		29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9826	003	0	1	01	01	H9826_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, Select Care Drugs																														
H9826	003	0	1	01	01	H9826_003_0	5		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				23.43	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9826	003	0	1	01	01	H9826_003_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				55.95	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	25	25	25				25	25	25				25		25
H9826	003	0	1	01	01	H9826_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				36.68	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	25	25	25				25	25	25				25		25
H9826	003	0	1	01	01	H9826_003_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				397.72	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9826	003	0	1	01	01	H9826_003_0	5		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9826	004	0	1	01	01	H9826_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, Select Care Drugs																														
H9826	004	0	1	01	01	H9826_004_0	5		N	Generic	4	01	1	1	2	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				23.43	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9826	004	0	1	01	01	H9826_004_0	5		N	Preferred Brand	4	10	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				55.95	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	25	25	25				25	25	25				25		25
H9826	004	0	1	01	01	H9826_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				36.68	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	25	25	25				25	25	25				25		25
H9826	004	0	1	01	01	H9826_004_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				397.72	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9826	004	0	1	01	01	H9826_004_0	5		N	Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
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	0	0	0				0	0	0				0		0
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	25	25	25				0	0	0				25		25
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				40.27	25	25	25																		25	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	25	25	25				25	25	25				25		25
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				87.75	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	70.00				35.00		35.00	25	25	25				25	25	25				25		25
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					31																				31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9827	004	0	1	01	01	H9827_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9827	004	0	1	01	01	H9827_004_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	25	25	25				0	0	0				25		25
H9827	004	0	1	01	01	H9827_004_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	90				1	2	30	60	90				30		31				47.39	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	25	25	25				25	25	25				25		25
H9827	004	0	1	01	01	H9827_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				74.27	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	25	25	25				25	25	25				25		25
H9827	004	0	1	01	01	H9827_004_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31					29																				29																	29			29								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9834	001	0	1	01	01	H9834_001_0	5			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	5.00																			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, Select Care Drugs																														
H9834	001	0	1	01	01	H9834_001_0	5			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	25.00																			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																														
H9834	001	0	1	01	01	H9834_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				55.11	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	20	20	20				20	20	20				20		20
H9834	001	0	1	01	01	H9834_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				69.04	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		35.00	25	25	25				25	25	25				25		25
H9834	001	0	1	01	01	H9834_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																														
H9834	001	0	1	01	01	H9834_001_0	5			Select Care Drugs	4	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9834	003	0	1	01	01	H9834_003_0	4			Preferred Generic	4	01	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	2.00	4.00	5.00																			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, Select Care Drugs																														
H9834	003	0	1	01	01	H9834_003_0	4			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	25.00																			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																														
H9834	003	0	1	01	01	H9834_003_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				64.55	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	20	20	20				20	20	20				20		20
H9834	003	0	1	01	01	H9834_003_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				72.36	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		35.00	25	25	25				25	25	25				25		25
H9834	003	0	1	01	01	H9834_003_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					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	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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9834	006	0	1	01	01	H9834_006_0	4			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	5.00																			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, Select Care Drugs																														
H9834	006	0	1	01	01	H9834_006_0	4			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	25.00																			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																														
H9834	006	0	1	01	01	H9834_006_0	4			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				69.76	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	20	20	20				20	20	20				20		20
H9834	006	0	1	01	01	H9834_006_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				79.50	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		35.00	25	25	25				25	25	25				25		25
H9834	006	0	1	01	01	H9834_006_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9834	006	0	1	01	01	H9834_006_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9834	007	0	1	01	01	H9834_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	2.00	4.00	5.00																			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, Select Care Drugs																														
H9834	007	0	1	01	01	H9834_007_0	4			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	25.00																			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																														
H9834	007	0	1	01	01	H9834_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				68.21	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		35.00	20	20	20				20	20	20				20		20
H9834	007	0	1	01	01	H9834_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				74.23	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		35.00	25	25	25				25	25	25				25		25
H9834	007	0	1	01	01	H9834_007_0	4			Specialty Tier	4	11	1	1	5	1	010		01	000		1	30														30		31					30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9834	007	0	1	01	01	H9834_007_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9884	008	0	1	04	01	H9884_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	0	0	0				0	0	0				0		0
H9884	008	0	1	04	01	H9884_008_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	25	25	25				25	25	25				25		25
H9884	008	0	1	04	01	H9884_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				35.00	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	21	21	21				21	21	21				21		21
H9884	008	0	1	04	01	H9884_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				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	25	25	25				25	25	25				25		25
H9884	008	0	1	04	01	H9884_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	25						25						25		25
H9884	013	0	1	04	01	H9884_013_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9884	013	0	1	04	01	H9884_013_0	6			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	25	25	25				25	25	25				25		25
H9884	013	0	1	04	01	H9884_013_0	6			Preferred Brand	4	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	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	22	22	22				22	22	22				22		22
H9884	013	0	1	04	01	H9884_013_0	6			Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				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	25	25	25				25	25	25				25		25
H9884	013	0	1	04	01	H9884_013_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	25						25						25		25
H9884	015	0	1	04	01	H9884_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	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9884	015	0	1	04	01	H9884_015_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	0	0	0				0	0	0				0		0
H9884	015	0	1	04	01	H9884_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				60.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9884	015	0	1	04	01	H9884_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				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	25	25	25				25	25	25				25		25
H9884	015	0	1	04	01	H9884_015_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	25						25						25		25
H9888	001	0	1	04	01	H9888_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	0	0	0				0	0	0				0		0
H9888	001	0	1	04	01	H9888_001_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	0	0	0				0	0	0				0		0
H9888	001	0	1	04	01	H9888_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				54.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9888	001	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	001	0	1	04	01	H9888_001_0	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	25						25						25		25
H9888	002	0	1	04	01	H9888_002_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	0	0	0				0	0	0				0		0
H9888	002	0	1	04	01	H9888_002_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	0	0	0				0	0	0				0		0
H9888	002	0	1	04	01	H9888_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				57.00	24	24	24																		24	24	24															24			24								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	24	24	24				24	24	24				24		24
H9888	002	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	002	0	1	04	01	H9888_002_0	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	25						25						25		25
H9888	005	0	1	04	01	H9888_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9888	005	0	1	04	01	H9888_005_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	25	25	25				25	25	25				25		25
H9888	005	0	1	04	01	H9888_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				39.00	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	21	21	21				21	21	21				21		21
H9888	005	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	005	0	1	04	01	H9888_005_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	25						25						25		25
H9888	006	0	1	04	01	H9888_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	0	0	0				0	0	0				0		0
H9888	006	0	1	04	01	H9888_006_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	25	25	25				25	25	25				25		25
H9888	006	0	1	04	01	H9888_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				39.00	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	21	21	21				21	21	21				21		21
H9888	006	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	006	0	1	04	01	H9888_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	25						25						25		25
H9888	008	0	1	04	01	H9888_008_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	0	0	0				0	0	0				0		0
H9888	008	0	1	04	01	H9888_008_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9888	008	0	1	04	01	H9888_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				32.00	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	20	20	20				20	20	20				20		20
H9888	008	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	008	0	1	04	01	H9888_008_0	6			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	25						25						25		25
H9888	009	0	1	04	01	H9888_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9888	009	0	1	04	01	H9888_009_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9888	009	0	1	04	01	H9888_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H9888	009	0	1	04	01	H9888_009_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9888	009	0	1	04	01	H9888_009_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	009	0	1	04	01	H9888_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9888	010	0	1	04	01	H9888_010_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	0	0	0				0	0	0				0		0
H9888	010	0	1	04	01	H9888_010_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9888	010	0	1	04	01	H9888_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				32.00	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	20	20	20				20	20	20				20		20
H9888	010	0	1	04	01	H9888_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				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	25	25	25				25	25	25				25		25
H9888	010	0	1	04	01	H9888_010_0	6			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	25						25						25		25
H9888	011	0	1	04	01	H9888_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9888	011	0	1	04	01	H9888_011_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9888	011	0	1	04	01	H9888_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				34.00	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		35.00	21	21	21				21	21	21				21		21
H9888	011	0	1	04	01	H9888_011_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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	25	25	25				25	25	25				25		25
H9888	011	0	1	04	01	H9888_011_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	011	0	1	04	01	H9888_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9888	012	0	1	04	01	H9888_012_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9888	012	0	1	04	01	H9888_012_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9888	012	0	1	04	01	H9888_012_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	012	0	1	04	01	H9888_012_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H9888	012	0	1	04	01	H9888_012_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	012	0	1	04	01	H9888_012_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9888	013	0	1	04	01	H9888_013_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H9888	013	0	1	04	01	H9888_013_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	013	0	1	04	01	H9888_013_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	013	0	1	04	01	H9888_013_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	013	0	1	04	01	H9888_013_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	013	0	1	04	01	H9888_013_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9888	014	0	1	04	01	H9888_014_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				1.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	34.00	68.00	102.00				34.00	68.00	102.00				34.00		34.00	25	25	25				25	25	25				25		25
H9888	014	0	1	04	01	H9888_014_0	5		N	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																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	014	0	1	04	01	H9888_014_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				44.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	014	0	1	04	01	H9888_014_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				62.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	014	0	1	04	01	H9888_014_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	014	0	1	04	01	H9888_014_0	5		N	Select Care Drugs	4	11	3	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9888	015	0	1	04	01	H9888_015_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9888	015	0	1	04	01	H9888_015_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9888	015	0	1	04	01	H9888_015_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9888	015	0	1	04	01	H9888_015_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H9888	015	0	1	04	01	H9888_015_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9888	015	0	1	04	01	H9888_015_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9904	001	0	1	04	01	H9904_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																														
H9904	001	0	1	04	01	H9904_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																														
H9904	001	0	1	04	01	H9904_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	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	25	25	25				25	25	25				25		25
H9904	001	0	1	04	01	H9904_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				88.86	40	40	40																		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		35.00	25	25	25				25	25	25				25		25
H9904	001	0	1	04	01	H9904_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				564.44	30	30	30																		30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9904	002	0	1	04	01	H9904_002_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9904	002	0	1	04	01	H9904_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																														
H9904	002	0	1	04	01	H9904_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	37.00	74.00	74.00																			37.00	74.00	74.00																37.00				37.00		1.23			1.23			1.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	70.00				35.00	70.00	70.00				35.00		35.00	25	25	25				25	25	25				25		25
H9904	002	0	1	04	01	H9904_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				51.26	30	30	30																		30	30	30															30			30								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	25	25	25				25	25	25				25		25
H9904	002	0	1	04	01	H9904_002_0	9			Specialty Tier	4	11	1	1	5	1	111		01	111		1	30	60	100				1	1	30	60	100				30		31				433.96	30	30	30																		30	30	30															30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9907	002	1	1	04	01	H9907_002_1	10			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H9907	002	1	1	04	01	H9907_002_1	10			Generic	4	01	3	2	2	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					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H9907	002	1	1	04	01	H9907_002_1	10			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											54.66	20	20	20				55.19	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H9907	002	1	1	04	01	H9907_002_1	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											65.13	25	25	25				68.39	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	25	25	25	25	25	25	25	25	25				25		25
H9907	002	1	1	04	01	H9907_002_1	10			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, Vaccines																														
H9907	002	1	1	04	01	H9907_002_1	10			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																														
H9907	002	2	1	04	01	H9907_002_2	10			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H9907	002	2	1	04	01	H9907_002_2	10			Generic	4	01	3	2	2	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					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H9907	002	2	1	04	01	H9907_002_2	10			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											54.66	20	20	20				55.19	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H9907	002	2	1	04	01	H9907_002_2	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											65.13	25	25	25				68.39	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	25	25	25	25	25	25	25	25	25				25		25
H9907	002	2	1	04	01	H9907_002_2	10			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, Vaccines																														
H9907	002	2	1	04	01	H9907_002_2	10			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																														
H9907	002	3	1	04	01	H9907_002_3	10			Preferred Generic	4	01	3	2	1	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31								5.00	10.00	15.00					0.00	0.00	0.00					0.00	0.00	0.00																5.00				0.00			0.17	0.00	0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	5.00	10.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00				5.00		0.00	25	25	25	0	0	0	0	0	0				25		0
H9907	002	3	1	04	01	H9907_002_3	10			Generic	4	01	3	2	2	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					2.00	4.00	4.00																12.00				2.00			0.40	0.07	0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Vaccines	12.00	24.00	36.00	2.00	4.00	6.00	2.00	4.00	4.00				12.00		2.00	25	25	25	25	25	25	25	25	25				25		25
H9907	002	3	1	04	01	H9907_002_3	10			Preferred Brand	4	11	1	1	3	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											54.66	20	20	20				55.19	20	20	20				20	20	20															20			20								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	20	20	20	20	20	20	20	20	20				20		20
H9907	002	3	1	04	01	H9907_002_3	10			Non-Preferred Drug	4	11	1	1	4	1		111	01	111		1				30	60	90	1	2	30	60	90				30		31											65.13	25	25	25				68.39	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	25	25	25	25	25	25	25	25	25				25		25
H9907	002	3	1	04	01	H9907_002_3	10			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, Vaccines																														
H9907	002	3	1	04	01	H9907_002_3	10			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																														
H9916	001	0	1	02	01	H9916_001_0	8		N	Preferred Generic	3	11	1	2	1	1		111	01		101	1				30	60	100	1	2					60	100	30		31								19.00	38.00	57.00					18.00	36.00	54.00												38.00	57.00					36.00	0.00				19.00				19.00			0.63	0.60				0.61	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9916	001	0	1	02	01	H9916_001_0	8		N	Generic	3	11	1	2	2	1		111	01		101	1				30	60	100	1	2					60	100	30		31								20.00	40.00	60.00					19.00	38.00	57.00												40.00	60.00					38.00	0.00				20.00				20.00			0.67	0.63				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9916	001	0	1	02	01	H9916_001_0	8		N	Preferred Brand	3	11	1	1	3	1		111	01		101	1				30	60	100	1	2					60	100	30		31											77.93	20	20	20				77.93	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		70.00	105.00		70.00	105.00	35.00		35.00	20	20	20	20	20	20		20	20		20	20	20		20
H9916	001	0	1	02	01	H9916_001_0	8		N	Non-Preferred Drug	3	11	1	2	4	1		111	01		101	1				30	60	100	1	2					60	100	30		31								100.00	200.00	300.00					100.00	200.00	300.00												200.00	300.00					200.00	200.00				100.00				100.00			3.33	3.33				3.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
H9916	001	0	1	02	01	H9916_001_0	8		N	Specialty Tier	3	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9916	001	0	1	02	01	H9916_001_0	8		N	Select Care Drugs	3	11	1	2	6	1		111	01		101	1				30	60	100	1	2					60	100	30		31								0.00	0.00	0.00					0.00	0.00	0.00												0.00	0.00					0.00	0.00				0.00				0.00			0.00	0.00				0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9917	004	0	1	01	01	H9917_004_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 Drug, Specialty Tier																														
H9917	004	0	1	01	01	H9917_004_0	5			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 Drug, Specialty Tier																														
H9917	004	0	1	01	01	H9917_004_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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9917	004	0	1	01	01	H9917_004_0	5			Non-Preferred Drug	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 Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9917	004	0	1	01	01	H9917_004_0	5			Specialty Tier	4	11	1	1	5	1	010		10	010		1	30								30							10	31				797.12	27																				27																		27		27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
H9955	007	0	1	01	01	H9955_007_0	8		N	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																														
H9955	007	0	1	01	01	H9955_007_0	8		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.56	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9955	007	0	1	01	01	H9955_007_0	8		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				35.10	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	20	20	20				20	20	20				20		20
H9955	007	0	1	01	01	H9955_007_0	8		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				65.10	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		35.00	25	25	25				25	25	25				25		25
H9955	007	0	1	01	01	H9955_007_0	8		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				489.39	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	25						25						25		25
H9955	007	0	1	01	01	H9955_007_0	8		N	Select Care Drugs	4	01	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																														
H9955	008	0	1	01	01	H9955_008_0	9		N	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																														
H9955	008	0	1	01	01	H9955_008_0	9		N	Generic	4	11	1	1	2	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				4.90	20	20	20																		20	20	20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9955	008	0	1	01	01	H9955_008_0	9		N	Preferred Brand	4	11	1	1	3	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				24.31	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		35.00	20	20	20				20	20	20				20		20
H9955	008	0	1	01	01	H9955_008_0	9		N	Non-Preferred Drug	4	11	1	1	4	1	111		01	111		1	31	60	100				1	2	31	60	100				31		31				52.23	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		35.00	25	25	25				25	25	25				25		25
H9955	008	0	1	01	01	H9955_008_0	9		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				421.11	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	25						25						25		25
H9955	008	0	1	01	01	H9955_008_0	9		N	Select Care Drugs	4	01	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																														
H9977	001	0	1	01	01	H9977_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	0	0	0				0	0	0				0		0
H9977	001	0	1	01	01	H9977_001_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9977	001	0	1	01	01	H9977_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				32.00	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	19	19	19				19	19	19				19		19
H9977	001	0	1	01	01	H9977_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				59.00	25	25	25																		25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9977	001	0	1	01	01	H9977_001_0	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	25						25						25		25
H9977	002	0	1	01	01	H9977_002_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	0	0	0				0	0	0				0		0
H9977	002	0	1	01	01	H9977_002_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	25	25	25				25	25	25				25		25
H9977	002	0	1	01	01	H9977_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				39.00	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	21	21	21				21	21	21				21		21
H9977	002	0	1	01	01	H9977_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				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	25	25	25				25	25	25				25		25
H9977	002	0	1	01	01	H9977_002_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	25						25						25		25
H9977	003	0	1	01	01	H9977_003_0	6			Preferred Generic	3	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																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9977	003	0	1	01	01	H9977_003_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H9977	003	0	1	01	01	H9977_003_0	6			Preferred Brand	3	11	1	1	3	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				36.00	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		35.00	23	23	23				23	23	23				23		23
H9977	003	0	1	01	01	H9977_003_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9977	003	0	1	01	01	H9977_003_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9977	003	0	1	01	01	H9977_003_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9977	004	0	1	01	01	H9977_004_0	6			Preferred Generic	3	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9977	004	0	1	01	01	H9977_004_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	19.00	38.00	57.00																			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, Select Care Drugs	19.00	38.00	57.00				19.00	38.00	57.00				19.00		19.00	25	25	25				25	25	25				25		25
H9977	004	0	1	01	01	H9977_004_0	6			Preferred Brand	3	11	1	1	3	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, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9977	004	0	1	01	01	H9977_004_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				73.00	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		35.00	25	25	25				25	25	25				25		25
H9977	004	0	1	01	01	H9977_004_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9977	004	0	1	01	01	H9977_004_0	6			Select Care Drugs	3	11	1	2	6	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
H9977	005	0	1	01	01	H9977_005_0	6			Preferred Generic	4	11	1	2	1	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	0.00	0.00	0.00																			0.00	0.00	0.00																0.00				0.00		0.00			0.00			0.00	Preferred Generic, 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	0	0				0	0	0				0		0
H9977	005	0	1	01	01	H9977_005_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	0.00	0.00	0.00				0.00	0.00	0.00				0.00		0.00	0	0	0				0	0	0				0		0
H9977	005	0	1	01	01	H9977_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				31.00	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	19	19	19				19	19	19				19		19
H9977	005	0	1	01	01	H9977_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				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	25	25	25				25	25	25				25		25
H9977	005	0	1	01	01	H9977_005_0	6			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30								30						30		31				1.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
H9977	006	0	1	01	01	H9977_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	0	0	0				0	0	0				0		0
H9977	006	0	1	01	01	H9977_006_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	25	25	25				25	25	25				25		25
H9977	006	0	1	01	01	H9977_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				39.00	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	21	21	21				21	21	21				21		21
H9977	006	0	1	01	01	H9977_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				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	25	25	25				25	25	25				25		25
H9977	006	0	1	01	01	H9977_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	25						25						25		25
H9977	007	0	1	01	01	H9977_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	18.00	36.00	54.00																			18.00	36.00	54.00																18.00				18.00		0.60			0.60			0.58	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	18.00	36.00	54.00				18.00	36.00	54.00				18.00		18.00	25	25	25				25	25	25				25		25
H9977	007	0	1	01	01	H9977_007_0	6			Generic	3	11	1	2	2	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31	20.00	40.00	60.00																			20.00	40.00	60.00																20.00				20.00		0.67			0.67			0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	20.00	40.00	60.00				20.00	40.00	60.00				20.00		20.00	25	25	25				25	25	25				25		25
H9977	007	0	1	01	01	H9977_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				36.00	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		35.00	23	23	23				23	23	23				23		23
H9977	007	0	1	01	01	H9977_007_0	6			Non-Preferred Drug	3	11	1	1	4	1	111		01	111		1	30	60	100				1	2	30	60	100				30		31				59.00	26	26	26																		26	26	26															26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
H9977	007	0	1	01	01	H9977_007_0	6			Specialty Tier	3	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, Select Care Drugs	35.00						35.00						35.00		35.00	25						25						25		25
H9977	007	0	1	01	01	H9977_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	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
R0110	003	0	1	31	11	R0110_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																									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	0		0				25		25	0		0	0		0
R0110	003	0	1	31	11	R0110_003_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
R0110	003	0	1	31	11	R0110_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	25		25				25		25	25		25	25		25
R0110	003	0	1	31	11	R0110_003_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				70.00	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	25		25				25		25	25		25	25		25
R0110	003	0	1	31	11	R0110_003_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	25						25			25			25		25
R0110	005	0	1	31	11	R0110_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	0		0				25		25	0		0	0		0
R0110	005	0	1	31	11	R0110_005_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
R0110	005	0	1	31	11	R0110_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	25		25				25		25	25		25	25		25
R0110	005	0	1	31	11	R0110_005_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	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	25		25				25		25	25		25	25		25
R0110	005	0	1	31	11	R0110_005_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	25						25			25			25		25
R0110	008	0	1	31	11	R0110_008_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	0		0				25		25	0		0	0		0
R0110	008	0	1	31	11	R0110_008_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
R0110	008	0	1	31	11	R0110_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	25		25				25		25	25		25	25		25
R0110	008	0	1	31	11	R0110_008_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	25		25				25		25	25		25	25		25
R0110	008	0	1	31	11	R0110_008_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	25						25			25			25		25
R0110	012	0	1	31	11	R0110_012_0	2			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	0		0				25		25	0		0	0		0
R0110	012	0	1	31	11	R0110_012_0	2			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	25		25				25		25	25		0	25		25
R0110	012	0	1	31	11	R0110_012_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R0110	012	0	1	31	11	R0110_012_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				62.00	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	25		25				25		25	25		25	25		25
R0110	012	0	1	31	11	R0110_012_0	2			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	25						25			25			25		25
R0110	018	0	1	31	11	R0110_018_0	2			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	0		0				25		25	0		0	0		0
R0110	018	0	1	31	11	R0110_018_0	2			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	25		25				25		25	25		0	25		25
R0110	018	0	1	31	11	R0110_018_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R0110	018	0	1	31	11	R0110_018_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				58.00	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	25		25				25		25	25		25	25		25
R0110	018	0	1	31	11	R0110_018_0	2			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	25						25			25			25		25
R0110	020	0	1	31	11	R0110_020_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	0		0				25		25	0		0	0		0
R0110	020	0	1	31	11	R0110_020_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
R0110	020	0	1	31	11	R0110_020_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	25		25				25		25	25		25	25		25
R0110	020	0	1	31	11	R0110_020_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				68.00	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	25		25				25		25	25		25	25		25
R0110	020	0	1	31	11	R0110_020_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	25						25			25			25		25
R0759	001	0	1	31	11	R0759_001_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R0759	001	0	1	31	11	R0759_001_0	4			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		0.27						0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R0759	001	0	1	31	11	R0759_001_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				34.00	17		17																										17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	17		17						17			17	17		17
R0759	001	0	1	31	11	R0759_001_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				78.00	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	25						25			25			25		25
R0759	001	0	1	31	11	R0759_001_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
R0759	003	0	1	31	11	R0759_003_0	5		N	Preferred Generic	4	01	1	2	1	1	110		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																														
R0759	003	0	1	31	11	R0759_003_0	5		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R0759	003	0	1	31	11	R0759_003_0	5		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				47.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	25		25						25				25		25
R0759	003	0	1	31	11	R0759_003_0	5		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R0759	003	0	1	31	11	R0759_003_0	5		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				352.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R1532	002	0	1	31	11	R1532_002_0	2			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	0		0				25		25	0		0	0		0
R1532	002	0	1	31	11	R1532_002_0	2			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	25		25				25		25	25		0	25		25
R1532	002	0	1	31	11	R1532_002_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R1532	002	0	1	31	11	R1532_002_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				61.00	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	25		25				25		25	25		25	25		25
R1532	002	0	1	31	11	R1532_002_0	2			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	25						25			25			25		25
R3444	009	0	1	31	11	R3444_009_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R3444	009	0	1	31	11	R3444_009_0	4			Generic	4	01	3	2	2	1	110		01	100		1	30		100				2	2			100				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																														
R3444	009	0	1	31	11	R3444_009_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				45.00	19		19																				19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00				25.00		25.00	19		19						19				19		19
R3444	009	0	1	31	11	R3444_009_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				49.00	30																				30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R3444	009	0	1	31	11	R3444_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				374.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R3444	012	0	1	31	11	R3444_012_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R3444	012	0	1	31	11	R3444_012_0	4			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																														
R3444	012	0	1	31	11	R3444_012_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				37.00	20		20																				20															20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00				35.00		35.00	20		20						20				20		20
R3444	012	0	1	31	11	R3444_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				64.00	35																				35																	35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R3444	012	0	1	31	11	R3444_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				337.00	26																				26																	26			26								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R4182	003	0	1	31	11	R4182_003_0	2			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	0		0				25		25	0		0	0		0
R4182	003	0	1	31	11	R4182_003_0	2			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	25		25				25		25	25		0	25		25
R4182	003	0	1	31	11	R4182_003_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R4182	003	0	1	31	11	R4182_003_0	2			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	25		25				25		25	25		25	25		25
R4182	003	0	1	31	11	R4182_003_0	2			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	25						25			25			25		25
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	0.00		0.00																									10.00		30.00				0.00		0.00				0.00				0.00		0.00				0.33	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				10.00		30.00	0.00		0.00	0.00		0.00	0		0				25		25	0		0	0		0
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	5.00		15.00																									20.00		60.00				5.00		0.00				5.00				5.00		0.17				0.67	0.17	0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
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	25		25				25		25	25		25	25		25
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				71.00	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	25		25				25		25	25		25	25		25
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					25																										25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
R5361	002	0	1	31	11	R5361_002_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	0		0				25		25	0		0	0		0
R5361	002	0	1	31	11	R5361_002_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	5.00		15.00				20.00		60.00	5.00		0.00	5.00		5.00	25		25				25		25	25		0	25		25
R5361	002	0	1	31	11	R5361_002_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	25		25				25		25	25		25	25		25
R5361	002	0	1	31	11	R5361_002_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	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	25		25				25		25	25		25	25		25
R5361	002	0	1	31	11	R5361_002_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	25						25			25			25		25
R5826	005	0	1	31	11	R5826_005_0	2			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	0		0				25		25	0		0	0		0
R5826	005	0	1	31	11	R5826_005_0	2			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	25		25				25		25	25		0	25		25
R5826	005	0	1	31	11	R5826_005_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R5826	005	0	1	31	11	R5826_005_0	2			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	25		25				25		25	25		25	25		25
R5826	005	0	1	31	11	R5826_005_0	2			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	25						25			25			25		25
R5941	014	0	1	31	11	R5941_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																														
R5941	014	0	1	31	11	R5941_014_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																														
R5941	014	0	1	31	11	R5941_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											44.00	25	25	25				73.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
R5941	014	0	1	31	11	R5941_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											27.00	30	30	30				16.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
R5941	014	0	1	31	11	R5941_014_0	6			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		34												30							30						30																	30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
R5941	014	0	1	31	11	R5941_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																														
R5941	016	0	1	31	11	R5941_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								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																														
R5941	016	0	1	31	11	R5941_016_0	6			Generic	4	11	1	2	2	1		111	01	111		1				30	60	90	2	2	30	60	90				30		34								13.00	26.00	39.00					8.00	16.00	24.00					0.00	0.00	0.00																13.00				13.00			0.43	0.27	0.00			0.38	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
R5941	016	0	1	31	11	R5941_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											39.00	25	25	25				66.00	25	25	25				25	25	25															25			25								Preferred Generic, Generic, Preferred Brand, 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	25	25	25	25	25	25	25	25	25				25		25
R5941	016	0	1	31	11	R5941_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											24.00	30	30	30				17.00	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		35.00	25	25	25	25	25	25	25	25	25				25		25
R5941	016	0	1	31	11	R5941_016_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																														
R5941	016	0	1	31	11	R5941_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																														
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											70.94	24	24	24				99.08	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	24	24	24	24	24	24	24	24	24	24	24	24	24		24
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											43.30	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											566.06	25						576.89	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	25			25			25			25			25		25
R6801	008	0	1	31	11	R6801_008_0	4			Preferred Generic	4	01	1	2	1	1	110		01	100		1	30		100				2	2			100				30		31	0.00		0.00																					0.00																0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	008	0	1	31	11	R6801_008_0	4			Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	008	0	1	31	11	R6801_008_0	4			Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				63.00	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	25		25						25				25		25
R6801	008	0	1	31	11	R6801_008_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R6801	008	0	1	31	11	R6801_008_0	4			Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				362.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R6801	009	0	1	31	11	R6801_009_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	009	0	1	31	11	R6801_009_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	009	0	1	31	11	R6801_009_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				55.00	20		20																										20						20			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	25.00		75.00						75.00			75.00	25.00		25.00	20		20						20			20	20		20
R6801	009	0	1	31	11	R6801_009_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
R6801	009	0	1	31	11	R6801_009_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				373.00	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	25						25			25			25		25
R6801	011	0	1	31	11	R6801_011_0	4		N	Preferred Generic	4	01	1	2	1	1	110		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																														
R6801	011	0	1	31	11	R6801_011_0	4		N	Generic	4	01	1	1	2	1	110		01	100		1	30		100				2	2			100				30		31				5.00	25		25																				25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	011	0	1	31	11	R6801_011_0	4		N	Preferred Brand	4	11	1	1	3	1	110		01	100		1	30		100				2	2			100				30		31				52.00	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	25		25						25				25		25
R6801	011	0	1	31	11	R6801_011_0	4		N	Non-Preferred Drug	4	11	1	1	4	1	010		01	010		1	30						2	2	30						30		31				48.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R6801	011	0	1	31	11	R6801_011_0	4		N	Specialty Tier	4	11	1	1	5	1	010		01	010		1	30						2	2	30						30		31				371.00	25																				25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
R6801	012	0	1	31	11	R6801_012_0	4			Preferred Generic	4	01	1	2	1	1	110		01		100	1	30		100				2	2						100	30		31	0.00		0.00																											0.00						0.00				0.00				0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	012	0	1	31	11	R6801_012_0	4			Generic	4	01	3	2	2	1	110		01		100	1	30		100				2	2						100	30		31	14.00		42.00																											42.00						0.00				14.00				14.00		0.47						0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
R6801	012	0	1	31	11	R6801_012_0	4			Preferred Brand	4	11	1	1	3	1	110		01		100	1	30		100				2	2						100	30		31				37.00	18		18																										18						18			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00						105.00			105.00	35.00		35.00	18		18						18			18	18		18
R6801	012	0	1	31	11	R6801_012_0	4			Non-Preferred Drug	4	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				64.00	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	25						25			25			25		25
R6801	012	0	1	31	11	R6801_012_0	4			Specialty Tier	4	11	1	1	5	1	010		01		010	1	30						2	2				30			30		31				354.00	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	25						25			25			25		25
R7220	002	0	1	31	11	R7220_002_0	2			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	0		0				25		25	0		0	0		0
R7220	002	0	1	31	11	R7220_002_0	2			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	25		25				25		25	25		0	25		25
R7220	002	0	1	31	11	R7220_002_0	2			Preferred Brand	4	11	1	2	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	25		25				25		25	25		25	25		25
R7220	002	0	1	31	11	R7220_002_0	2			Non-Preferred Drug	4	11	1	1	4	1	110		01		110	1	30		100				2	2				30		100	30		31				78.00	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	25		25				25		25	25		25	25		25
R7220	002	0	1	31	11	R7220_002_0	2			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	25						25			25			25		25
S1030	001	0		29	10	S1030_001_0	3			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	25		25				25		25				25		25
S1030	001	0		29	10	S1030_001_0	3			Generic	4	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	12.00		24.00																			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		24.00				12.00		24.00				12.00		12.00	25		25				25		25				25		25
S1030	001	0		29	10	S1030_001_0	3			Preferred Brand	4	10	1	2	3	1	110		01	110		1	30		100				1	2	30		100				30		31	47.00		94.00																			47.00		94.00																47.00				47.00		1.57			1.57			1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
S1030	001	0		29	10	S1030_001_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				43.90	42		42																		42		42															42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
S1030	001	0		29	10	S1030_001_0	3			Specialty Tier	4	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				564.37	31		31																		31		31															31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S1030	006	0		29	10	S1030_006_0	3			Preferred Generic	2	01	1	2	1	1	110		01	110		1	30		100				1	2	30		100				30		31	2.00		4.00																			2.00		4.00																2.00				2.00		0.07			0.07			0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		4.00				2.00		4.00				2.00		2.00	25		25				25		25				25		25
S1030	006	0		29	10	S1030_006_0	3			Generic	2	01	1	2	2	1	110		01	110		1	30		100				1	2	30		100				30		31	10.00		20.00																			10.00		20.00																10.00				10.00		0.33			0.33			0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		20.00				10.00		20.00				10.00		10.00	25		25				25		25				25		25
S1030	006	0		29	10	S1030_006_0	3			Preferred Brand	2	11	1	1	3	1	110		01	110		1	30		100				1	2	30		100				30		31				1.00	19		19																		19		19															19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	19		19				19		19				19		19
S1030	006	0		29	10	S1030_006_0	3			Non-Preferred Drug	2	11	1	1	4	1	110		01	110		1	30		100				1	2	30		100				30		31				54.12	41		41																		41		41															41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		70.00				35.00		70.00				35.00		35.00	25		25				25		25				25		25
S1030	006	0		29	10	S1030_006_0	3			Specialty Tier	2	11	1	1	5	1	110		01	110		1	30		100				1	2	30		100				30		31				506.06	25		25																		25		25															25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	003	0		29	10	S2468_003_0	4			Preferred Generic	3	01	1	2	1	1		111	01	100		1				30	60	90	2	2			90				30		31								9.00	18.00	27.00					0.00	0.00	0.00							0.00																9.00				9.00			0.30	0.00				0.29	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	003	0		29	10	S2468_003_0	4			Generic	3	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								20.00	40.00	60.00					7.00	14.00	17.50							17.50																20.00				20.00			0.67	0.23				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	003	0		29	10	S2468_003_0	4			Preferred Brand	3	11	1	1	3	1		111	01	100		1				30	60	90	2	2			90				30		31											40.24	19	19	19				40.15	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			105.00				35.00		35.00	19	19	19	19	19	19			19				19		19
S2468	003	0		29	10	S2468_003_0	4			Non-Preferred Drug	3	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											77.26	49	49	49				50.90	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
S2468	003	0		29	10	S2468_003_0	4			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											581.92	25						446.60	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	004	0		29	10	S2468_004_0	4			Preferred Generic	4	01	1	2	1	1		111	01	100		1				30	60	90	2	2			90				30		31								11.00	22.00	33.00					0.00	0.00	0.00							0.00																11.00				11.00			0.37	0.00				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	004	0		29	10	S2468_004_0	4			Generic	4	01	1	2	2	1		111	01	100		1				30	60	90	2	2			90				30		31								14.00	28.00	42.00					7.00	14.00	14.00							14.00																14.00				14.00			0.47	0.23				0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S2468	004	0		29	10	S2468_004_0	4			Preferred Brand	4	11	1	1	3	1		111	01	100		1				30	60	90	2	2			90				30		31											35.41	19	19	19				35.29	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			105.00				35.00		35.00	19	19	19	19	19	19			19				19		19
S2468	004	0		29	10	S2468_004_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01	100		1				30	60	90	2	2			90				30		31											70.27	37	37	37				53.93	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			105.00				35.00		35.00	25	25	25	25	25	25			25				25		25
S2468	004	0		29	10	S2468_004_0	4			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30					30						30		31											754.29	33						531.95	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								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	25	25	25	0	0	0	0	0	0				25		25
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								11.00	22.00	33.00					3.00	6.00	9.00					3.00	6.00	6.00																11.00				11.00			0.37	0.10	0.10			0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	3.00	6.00	9.00	3.00	6.00	6.00				11.00		11.00	25	25	25	25	25	25	25	25	25				25		25
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											31.56	25	25	25				27.69	17	17	17				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		35.00	25	25	25	17	17	17	17	17	17				25		25
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											79.95	46	46	46				55.87	32	32	32				32	32	32															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	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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	25	25	25	25	25	25	25	25	25				25		25
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											69.79	44	44	44				52.32	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	105.00				35.00		35.00	25	25	25	25	25	25	25	25	25				25		25
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	25			25			25						25		25
S4802	012	0		29	10	S4802_012_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	012	0		29	10	S4802_012_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	012	0		29	10	S4802_012_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											32.59	25	25	25				32.59	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	012	0		29	10	S4802_012_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											40.83	29	29	29				39.43	28	28	28											29	29					28	28			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	012	0		29	10	S4802_012_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	013	0		29	10	S4802_013_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	013	0		29	10	S4802_013_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	013	0		29	10	S4802_013_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											34.45	25	25	25				34.45	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	013	0		29	10	S4802_013_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											44.11	29	29	29				44.11	29	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	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	013	0		29	10	S4802_013_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	014	0		29	10	S4802_014_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					0.00	0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	014	0		29	10	S4802_014_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	014	0		29	10	S4802_014_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											36.41	25	25	25				36.41	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	014	0		29	10	S4802_014_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.95	26	26	26				35.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	014	0		29	10	S4802_014_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	020	0		29	10	S4802_020_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	020	0		29	10	S4802_020_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	020	0		29	10	S4802_020_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.81	25	25	25				35.81	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	020	0		29	10	S4802_020_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											39.83	28	28	28				39.83	28	28	28											28	28					28	28			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	020	0		29	10	S4802_020_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	021	0		29	10	S4802_021_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	021	0		29	10	S4802_021_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	021	0		29	10	S4802_021_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.62	25	25	25				35.62	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	021	0		29	10	S4802_021_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											39.56	28	28	28				38.14	27	27	27											28	28					27	27			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	021	0		29	10	S4802_021_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	069	0		29	10	S4802_069_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	069	0		29	10	S4802_069_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	069	0		29	10	S4802_069_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.87	25	25	25				35.87	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	069	0		29	10	S4802_069_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											47.91	31	31	31				47.91	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	069	0		29	10	S4802_069_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	070	0		29	10	S4802_070_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	070	0		29	10	S4802_070_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	070	0		29	10	S4802_070_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											32.88	25	25	25				32.88	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	070	0		29	10	S4802_070_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											39.77	27	27	27				39.77	27	27	27											27	27					27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	070	0		29	10	S4802_070_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	071	0		29	10	S4802_071_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	071	0		29	10	S4802_071_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	071	0		29	10	S4802_071_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											32.26	25	25	25				32.26	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	071	0		29	10	S4802_071_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											37.56	28	28	28				36.22	27	27	27											28	28					27	27			28			28								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	071	0		29	10	S4802_071_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	072	0		29	10	S4802_072_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	072	0		29	10	S4802_072_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	072	0		29	10	S4802_072_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											33.11	25	25	25				33.11	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	072	0		29	10	S4802_072_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											38.96	26	26	26				38.96	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	072	0		29	10	S4802_072_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	073	0		29	10	S4802_073_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	073	0		29	10	S4802_073_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	073	0		29	10	S4802_073_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.16	25	25	25				35.16	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	073	0		29	10	S4802_073_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.81	27	27	27				34.49	26	26	26											27	27					26	26			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	073	0		29	10	S4802_073_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	074	0		29	10	S4802_074_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	074	0		29	10	S4802_074_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	074	0		29	10	S4802_074_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											32.10	25	25	25				32.10	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	074	0		29	10	S4802_074_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											37.55	29	29	29				37.55	29	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	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	074	0		29	10	S4802_074_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	075	0		29	10	S4802_075_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	075	0		29	10	S4802_075_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	075	0		29	10	S4802_075_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.10	25	25	25				35.10	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	075	0		29	10	S4802_075_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.39	27	27	27				42.39	27	27	27											27	27					27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	075	0		29	10	S4802_075_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	076	0		29	10	S4802_076_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	076	0		29	10	S4802_076_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	076	0		29	10	S4802_076_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											36.52	25	25	25				36.52	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	076	0		29	10	S4802_076_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.27	30	30	30				46.66	29	29	29											30	30					29	29			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	076	0		29	10	S4802_076_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	077	0		29	10	S4802_077_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	077	0		29	10	S4802_077_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	077	0		29	10	S4802_077_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											31.94	25	25	25				31.94	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	077	0		29	10	S4802_077_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											51.49	29	29	29				49.71	28	28	28											29	29					28	28			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	077	0		29	10	S4802_077_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	078	0		29	10	S4802_078_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	078	0		29	10	S4802_078_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	078	0		29	10	S4802_078_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											30.87	25	25	25				30.87	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	078	0		29	10	S4802_078_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											50.11	30	30	30				48.44	29	29	29											30	30					29	29			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	078	0		29	10	S4802_078_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	079	0		29	10	S4802_079_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	079	0		29	10	S4802_079_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	079	0		29	10	S4802_079_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.20	25	25	25				35.20	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	079	0		29	10	S4802_079_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.30	31	31	31				48.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	079	0		29	10	S4802_079_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	080	0		29	10	S4802_080_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	080	0		29	10	S4802_080_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	080	0		29	10	S4802_080_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											33.20	25	25	25				33.20	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	080	0		29	10	S4802_080_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											41.85	29	29	29				40.41	28	28	28											29	29					28	28			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	080	0		29	10	S4802_080_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	081	0		29	10	S4802_081_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	081	0		29	10	S4802_081_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	081	0		29	10	S4802_081_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											33.65	25	25	25				33.65	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	081	0		29	10	S4802_081_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											44.96	29	29	29				41.86	27	27	27											29	29					27	27			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	081	0		29	10	S4802_081_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	082	0		29	10	S4802_082_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	082	0		29	10	S4802_082_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	082	0		29	10	S4802_082_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											31.71	25	25	25				31.71	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	082	0		29	10	S4802_082_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											43.40	30	30	30				40.51	28	28	28											30	30					28	28			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	082	0		29	10	S4802_082_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	083	0		29	10	S4802_083_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	083	0		29	10	S4802_083_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	083	0		29	10	S4802_083_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											29.38	25	25	25				29.38	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	083	0		29	10	S4802_083_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											43.75	29	29	29				42.24	28	28	28											29	29					28	28			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	083	0		29	10	S4802_083_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	084	0		29	10	S4802_084_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	084	0		29	10	S4802_084_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	084	0		29	10	S4802_084_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.32	25	25	25				35.32	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	084	0		29	10	S4802_084_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											40.88	30	30	30				38.15	28	28	28											30	30					28	28			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	084	0		29	10	S4802_084_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	085	0		29	10	S4802_085_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	085	0		29	10	S4802_085_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	085	0		29	10	S4802_085_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											34.00	25	25	25				34.00	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	085	0		29	10	S4802_085_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											41.71	27	27	27				41.71	27	27	27											27	27					27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	085	0		29	10	S4802_085_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	086	0		29	10	S4802_086_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	086	0		29	10	S4802_086_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	086	0		29	10	S4802_086_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.97	25	25	25				35.97	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	086	0		29	10	S4802_086_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.43	29	29	29				39.50	27	27	27											29	29					27	27			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	086	0		29	10	S4802_086_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	087	0		29	10	S4802_087_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	087	0		29	10	S4802_087_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	087	0		29	10	S4802_087_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											34.85	25	25	25				34.85	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	087	0		29	10	S4802_087_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											47.23	32	32	32				45.76	31	31	31											32	32					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	087	0		29	10	S4802_087_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	088	0		29	10	S4802_088_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00												10.00	15.00					0.00	0.00				5.00				5.00			0.17	0.00				0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	088	0		29	10	S4802_088_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					9.00	18.00	27.00												40.00	60.00					18.00	27.00				20.00				20.00			0.67	0.30				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	088	0		29	10	S4802_088_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											34.88	25	25	25				34.88	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	088	0		29	10	S4802_088_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											36.93	26	26	26				36.93	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	088	0		29	10	S4802_088_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	089	0		29	10	S4802_089_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	089	0		29	10	S4802_089_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	089	0		29	10	S4802_089_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											35.42	25	25	25				35.42	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	089	0		29	10	S4802_089_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											39.31	27	27	27				39.31	27	27	27											27	27					27	27			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	089	0		29	10	S4802_089_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	090	0		29	10	S4802_090_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	090	0		29	10	S4802_090_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	090	0		29	10	S4802_090_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											40.34	25	25	25				40.34	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	090	0		29	10	S4802_090_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											46.83	33	33	33				43.99	31	31	31											33	33					31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	090	0		29	10	S4802_090_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	091	0		29	10	S4802_091_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	091	0		29	10	S4802_091_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	091	0		29	10	S4802_091_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											38.79	25	25	25				38.79	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	091	0		29	10	S4802_091_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.10	30	30	30				46.50	29	29	29											30	30					29	29			30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	091	0		29	10	S4802_091_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	092	0		29	10	S4802_092_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	092	0		29	10	S4802_092_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	092	0		29	10	S4802_092_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											40.68	25	25	25				40.68	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	092	0		29	10	S4802_092_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											55.61	34	34	34				52.34	32	32	32											34	34					32	32			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	092	0		29	10	S4802_092_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	093	0		29	10	S4802_093_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	093	0		29	10	S4802_093_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	093	0		29	10	S4802_093_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											37.89	25	25	25				37.89	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	093	0		29	10	S4802_093_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											51.53	32	32	32				49.92	31	31	31											32	32					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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	093	0		29	10	S4802_093_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	094	0		29	10	S4802_094_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	094	0		29	10	S4802_094_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	094	0		29	10	S4802_094_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											36.59	25	25	25				36.59	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	094	0		29	10	S4802_094_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											56.68	33	33	33				53.25	31	31	31											33	33					31	31			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	094	0		29	10	S4802_094_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	095	0		29	10	S4802_095_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	095	0		29	10	S4802_095_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	095	0		29	10	S4802_095_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.73	25	25	25				42.73	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	095	0		29	10	S4802_095_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											67.85	35	35	35				67.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	095	0		29	10	S4802_095_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	096	0		29	10	S4802_096_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	096	0		29	10	S4802_096_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	096	0		29	10	S4802_096_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.87	25	25	25				48.87	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	096	0		29	10	S4802_096_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											49.41	29	29	29				47.71	28	28	28											29	29					28	28			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	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	096	0		29	10	S4802_096_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	097	0		29	10	S4802_097_0	3			Preferred Generic	2	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								10.00	20.00	30.00					0.00	0.00	0.00												20.00	30.00					0.00	0.00				10.00				10.00			0.33	0.00				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	097	0		29	10	S4802_097_0	3			Generic	2	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					10.00	20.00	30.00												40.00	60.00					20.00	30.00				20.00				20.00			0.67	0.33				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	097	0		29	10	S4802_097_0	3			Preferred Brand	2	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											33.25	25	25	25				33.25	25	25	25											25	25					25	25			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	097	0		29	10	S4802_097_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											39.13	27	27	27				37.68	26	26	26											27	27					26	26			27			27								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	097	0		29	10	S4802_097_0	3			Specialty Tier	2	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S4802	132	0		29	10	S4802_132_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	132	0		29	10	S4802_132_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	132	0		29	10	S4802_132_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.91	25	25	25				58.91	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	132	0		29	10	S4802_132_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											47.79	50	50	50				38.23	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	132	0		29	10	S4802_132_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	132	0		29	10	S4802_132_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	133	0		29	10	S4802_133_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	133	0		29	10	S4802_133_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	133	0		29	10	S4802_133_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.20	25	25	25				52.20	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	133	0		29	10	S4802_133_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.81	50	50	50				34.25	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	133	0		29	10	S4802_133_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	133	0		29	10	S4802_133_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	134	0		29	10	S4802_134_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	134	0		29	10	S4802_134_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	134	0		29	10	S4802_134_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											67.44	25	25	25				67.44	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	134	0		29	10	S4802_134_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.39	50	50	50				46.71	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	134	0		29	10	S4802_134_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	134	0		29	10	S4802_134_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	135	0		29	10	S4802_135_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	135	0		29	10	S4802_135_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	135	0		29	10	S4802_135_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											62.16	25	25	25				62.16	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	135	0		29	10	S4802_135_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.13	50	50	50				41.70	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	135	0		29	10	S4802_135_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	135	0		29	10	S4802_135_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	136	0		29	10	S4802_136_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	136	0		29	10	S4802_136_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	136	0		29	10	S4802_136_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.88	25	25	25				63.88	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	136	0		29	10	S4802_136_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.25	50	50	50				46.60	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	136	0		29	10	S4802_136_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	136	0		29	10	S4802_136_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	137	0		29	10	S4802_137_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	137	0		29	10	S4802_137_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	137	0		29	10	S4802_137_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											68.72	25	25	25				68.72	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	137	0		29	10	S4802_137_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.87	50	50	50				51.10	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	137	0		29	10	S4802_137_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	137	0		29	10	S4802_137_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	138	0		29	10	S4802_138_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	138	0		29	10	S4802_138_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	138	0		29	10	S4802_138_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											68.02	25	25	25				68.02	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	138	0		29	10	S4802_138_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											67.21	50	50	50				53.77	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	138	0		29	10	S4802_138_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	138	0		29	10	S4802_138_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	139	0		29	10	S4802_139_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	139	0		29	10	S4802_139_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	139	0		29	10	S4802_139_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											70.76	25	25	25				70.76	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	139	0		29	10	S4802_139_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.58	50	50	50				50.86	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	139	0		29	10	S4802_139_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	139	0		29	10	S4802_139_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	140	0		29	10	S4802_140_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	140	0		29	10	S4802_140_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	140	0		29	10	S4802_140_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											68.45	25	25	25				68.45	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	140	0		29	10	S4802_140_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											56.25	50	50	50				45.00	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	140	0		29	10	S4802_140_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	140	0		29	10	S4802_140_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	141	0		29	10	S4802_141_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	141	0		29	10	S4802_141_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	141	0		29	10	S4802_141_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											62.61	25	25	25				62.61	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	141	0		29	10	S4802_141_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											55.01	50	50	50				44.01	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	141	0		29	10	S4802_141_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	141	0		29	10	S4802_141_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	142	0		29	10	S4802_142_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	142	0		29	10	S4802_142_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	142	0		29	10	S4802_142_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											67.85	25	25	25				67.85	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	142	0		29	10	S4802_142_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											53.22	50	50	50				42.57	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	142	0		29	10	S4802_142_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	142	0		29	10	S4802_142_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	143	0		29	10	S4802_143_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	143	0		29	10	S4802_143_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	143	0		29	10	S4802_143_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.16	25	25	25				63.16	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	143	0		29	10	S4802_143_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.27	50	50	50				38.61	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	143	0		29	10	S4802_143_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	143	0		29	10	S4802_143_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	144	0		29	10	S4802_144_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	144	0		29	10	S4802_144_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	144	0		29	10	S4802_144_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											62.38	25	25	25				62.38	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	144	0		29	10	S4802_144_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											50.74	50	50	50				40.59	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	144	0		29	10	S4802_144_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	144	0		29	10	S4802_144_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	145	0		29	10	S4802_145_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	145	0		29	10	S4802_145_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	145	0		29	10	S4802_145_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											60.29	25	25	25				60.29	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	145	0		29	10	S4802_145_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											49.47	50	50	50				39.57	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	145	0		29	10	S4802_145_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	145	0		29	10	S4802_145_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	146	0		29	10	S4802_146_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	146	0		29	10	S4802_146_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	146	0		29	10	S4802_146_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.25	25	25	25				63.25	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	146	0		29	10	S4802_146_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											56.14	50	50	50				44.91	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	146	0		29	10	S4802_146_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	146	0		29	10	S4802_146_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	147	0		29	10	S4802_147_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	147	0		29	10	S4802_147_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	147	0		29	10	S4802_147_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.55	25	25	25				58.55	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	147	0		29	10	S4802_147_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											45.62	50	50	50				36.49	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	147	0		29	10	S4802_147_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	147	0		29	10	S4802_147_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	148	0		29	10	S4802_148_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	148	0		29	10	S4802_148_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	148	0		29	10	S4802_148_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											62.41	25	25	25				62.41	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	148	0		29	10	S4802_148_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											53.52	50	50	50				42.82	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	148	0		29	10	S4802_148_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	148	0		29	10	S4802_148_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	149	0		29	10	S4802_149_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	149	0		29	10	S4802_149_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	149	0		29	10	S4802_149_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.02	25	25	25				63.02	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	149	0		29	10	S4802_149_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											54.93	50	50	50				43.94	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	149	0		29	10	S4802_149_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	149	0		29	10	S4802_149_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	150	0		29	10	S4802_150_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	150	0		29	10	S4802_150_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	150	0		29	10	S4802_150_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.54	25	25	25				58.54	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	150	0		29	10	S4802_150_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											49.15	50	50	50				39.32	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	150	0		29	10	S4802_150_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	150	0		29	10	S4802_150_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	151	0		29	10	S4802_151_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	151	0		29	10	S4802_151_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	151	0		29	10	S4802_151_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											59.95	25	25	25				59.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	151	0		29	10	S4802_151_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.37	50	50	50				41.90	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	151	0		29	10	S4802_151_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	151	0		29	10	S4802_151_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	152	0		29	10	S4802_152_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	152	0		29	10	S4802_152_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	152	0		29	10	S4802_152_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											54.82	25	25	25				54.82	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	152	0		29	10	S4802_152_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											43.38	50	50	50				34.70	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	152	0		29	10	S4802_152_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	152	0		29	10	S4802_152_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	153	0		29	10	S4802_153_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	153	0		29	10	S4802_153_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	153	0		29	10	S4802_153_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											51.95	25	25	25				51.95	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	153	0		29	10	S4802_153_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											37.84	50	50	50				30.28	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	153	0		29	10	S4802_153_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	153	0		29	10	S4802_153_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	154	0		29	10	S4802_154_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	154	0		29	10	S4802_154_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	154	0		29	10	S4802_154_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											48.63	25	25	25				48.63	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	154	0		29	10	S4802_154_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											41.11	50	50	50				32.89	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	154	0		29	10	S4802_154_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	154	0		29	10	S4802_154_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	155	0		29	10	S4802_155_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	155	0		29	10	S4802_155_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	155	0		29	10	S4802_155_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											62.50	25	25	25				62.50	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	155	0		29	10	S4802_155_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.11	50	50	50				41.69	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	155	0		29	10	S4802_155_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	155	0		29	10	S4802_155_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	156	0		29	10	S4802_156_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	156	0		29	10	S4802_156_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	156	0		29	10	S4802_156_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											55.30	25	25	25				55.30	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	156	0		29	10	S4802_156_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											44.00	50	50	50				35.20	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	156	0		29	10	S4802_156_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	156	0		29	10	S4802_156_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	157	0		29	10	S4802_157_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	157	0		29	10	S4802_157_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	157	0		29	10	S4802_157_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.48	25	25	25				52.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	157	0		29	10	S4802_157_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.68	50	50	50				34.15	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	157	0		29	10	S4802_157_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	157	0		29	10	S4802_157_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	158	0		29	10	S4802_158_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	158	0		29	10	S4802_158_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	158	0		29	10	S4802_158_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.05	25	25	25				52.05	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	158	0		29	10	S4802_158_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											42.94	50	50	50				34.35	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	158	0		29	10	S4802_158_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	158	0		29	10	S4802_158_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	159	0		29	10	S4802_159_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	159	0		29	10	S4802_159_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	159	0		29	10	S4802_159_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											76.75	25	25	25				76.75	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	159	0		29	10	S4802_159_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											52.84	50	50	50				42.28	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	159	0		29	10	S4802_159_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	159	0		29	10	S4802_159_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	160	0		29	10	S4802_160_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	160	0		29	10	S4802_160_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	160	0		29	10	S4802_160_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											69.86	25	25	25				69.86	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	160	0		29	10	S4802_160_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											60.40	50	50	50				48.32	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	160	0		29	10	S4802_160_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	160	0		29	10	S4802_160_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	161	0		29	10	S4802_161_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	161	0		29	10	S4802_161_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	161	0		29	10	S4802_161_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											66.80	25	25	25				66.80	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	161	0		29	10	S4802_161_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											61.36	50	50	50				49.09	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	161	0		29	10	S4802_161_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	161	0		29	10	S4802_161_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	162	0		29	10	S4802_162_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	162	0		29	10	S4802_162_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	162	0		29	10	S4802_162_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											56.48	25	25	25				56.48	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	162	0		29	10	S4802_162_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											45.47	50	50	50				36.37	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	162	0		29	10	S4802_162_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	162	0		29	10	S4802_162_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	163	0		29	10	S4802_163_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	163	0		29	10	S4802_163_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	163	0		29	10	S4802_163_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											72.52	25	25	25				72.52	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	163	0		29	10	S4802_163_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											64.16	50	50	50				51.33	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	163	0		29	10	S4802_163_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	163	0		29	10	S4802_163_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	164	0		29	10	S4802_164_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	164	0		29	10	S4802_164_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	164	0		29	10	S4802_164_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											78.68	25	25	25				78.68	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	164	0		29	10	S4802_164_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											63.56	50	50	50				50.84	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	164	0		29	10	S4802_164_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	164	0		29	10	S4802_164_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	165	0		29	10	S4802_165_0	4			Preferred Generic	4	11	1	2	1	1		111	01		101	1				30	60	90	1	2					60	90	30		31								15.00	30.00	45.00					0.00	0.00	0.00												30.00	45.00					0.00	0.00				15.00				15.00			0.50	0.00				0.48	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	165	0		29	10	S4802_165_0	4			Generic	4	11	1	2	2	1		111	01		101	1				30	60	90	1	2					60	90	30		31								20.00	40.00	60.00					3.00	6.00	9.00												40.00	60.00					6.00	9.00				20.00				20.00			0.67	0.10				0.65	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	165	0		29	10	S4802_165_0	4			Preferred Brand	4	11	1	1	3	1		111	01		101	1				30	60	90	1	2					60	90	30		31											61.25	25	25	25				61.25	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		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	165	0		29	10	S4802_165_0	4			Non-Preferred Drug	4	11	1	1	4	1		111	01		101	1				30	60	90	1	2					60	90	30		31											58.66	50	50	50				46.92	40	40	40											50	50					40	40			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs	35.00	70.00	105.00	35.00	70.00	105.00		70.00	105.00		70.00	105.00	35.00		35.00	25	25	25	25	25	25		25	25		25	25	25		25
S4802	165	0		29	10	S4802_165_0	4			Specialty Tier	4	11	1	1	5	1		010	01		000	1				30											30		31												25							25																							25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S4802	165	0		29	10	S4802_165_0	4			Select Care Drugs	4	11	1	2	6	1		111	01		101	1				30	60	90	1	2					60	90	30		31								11.00	22.00	33.00					11.00	22.00	33.00												22.00	33.00					22.00	33.00				11.00				11.00			0.37	0.37				0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S5540	002	0		29	10	S5540_002_0	6			Preferred Generic	3	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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	002	0		29	10	S5540_002_0	6			Generic	3	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								20.00	40.00	60.00					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	002	0		29	10	S5540_002_0	6			Preferred Brand	3	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											1.00	20	20	20				1.00	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	20	20	20	20	20	20	20	20	20	20	20	20	20		20
S5540	002	0		29	10	S5540_002_0	6			Non-Preferred Drug	3	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											52.25	32	32	32				51.89	32	32	32										32	32	32				32	32	32			32			32								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	002	0		29	10	S5540_002_0	6			Specialty Tier	3	11	1	1	5	1		010	01		010	1				30								30			30		31											692.30	25						704.27	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5540	004	0		29	10	S5540_004_0	9			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	004	0		29	10	S5540_004_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					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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	004	0		29	10	S5540_004_0	9			Preferred Brand	4	11	1	2	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								47.00	94.00	141.00					45.00	90.00	135.00											47.00	94.00	141.00				45.00	90.00	135.00				47.00				47.00			1.57	1.50		1.57	1.50	1.52	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	004	0		29	10	S5540_004_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											69.73	40	40	40				66.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5540	004	0		29	10	S5540_004_0	9			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											796.67	33						789.25	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
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								10.00		30.00					5.00		15.00											10.00		30.00				5.00		15.00				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	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											24.00	20		20				30.00	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	20		20	20		20	20		20	20		20	20		20
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											50.00	25		25				47.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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		2.00											6.00		18.00				1.00		2.00				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		10.00											10.00		30.00				5.00		10.00				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	1	3	1		110	01		110	1				31		90	1	2				31		90	31		31											20.00	24		24				22.00	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		105.00	35.00		35.00	24		24	24		24	24		24	24		24	24		24
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											47.00	27		27				46.00	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		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
S5593	003	0		29	10	S5593_003_0	4			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	4			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	4			Preferred Brand	4	11	1	1	3	1		110	01		100	1				31		90	1	2						90	31		31											75.84	25		25				75.84	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	20		20	20		20			20			20	20		20
S5593	003	0		29	10	S5593_003_0	4			Non-Preferred Drug	4	11	1	1	4	1		110	01		100	1				31		90	1	2						90	31		31											62.15	25		25				62.15	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	20		20	20		20			20			20	20		20
S5593	003	0		29	10	S5593_003_0	4			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																														
S5601	002	0		29	10	S5601_002_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	002	0		29	10	S5601_002_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	002	0		29	10	S5601_002_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				19.26	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	18	18	18				18	18	18				18		18
S5601	002	0		29	10	S5601_002_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				45.75	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	002	0		29	10	S5601_002_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				269.65	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	004	0		29	10	S5601_004_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	004	0		29	10	S5601_004_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				55.17	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	19	19	19				19	19	19				19		19
S5601	004	0		29	10	S5601_004_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				50.33	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	25	25	25				25	25	25				25		25
S5601	004	0		29	10	S5601_004_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				500.90	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	006	0		29	10	S5601_006_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	006	0		29	10	S5601_006_0	2			Generic	2	01	1	2	2	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31	6.00	12.00	18.00																			6.00	12.00	18.00																	6.00			6.00		0.20			0.20			0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5601	006	0		29	10	S5601_006_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				20.02	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	18	18	18				18	18	18				18		18
S5601	006	0		29	10	S5601_006_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				49.84	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	25	25	25				25	25	25				25		25
S5601	006	0		29	10	S5601_006_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				280.77	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	008	0		29	10	S5601_008_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	008	0		29	10	S5601_008_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	008	0		29	10	S5601_008_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.66	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	18	18	18				18	18	18				18		18
S5601	008	0		29	10	S5601_008_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				46.62	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	25	25	25				25	25	25				25		25
S5601	008	0		29	10	S5601_008_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				272.33	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	010	0		29	10	S5601_010_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	010	0		29	10	S5601_010_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	010	0		29	10	S5601_010_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.21	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	18	18	18				18	18	18				18		18
S5601	010	0		29	10	S5601_010_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				43.62	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	25	25	25				25	25	25				25		25
S5601	010	0		29	10	S5601_010_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				272.71	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	012	0		29	10	S5601_012_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	012	0		29	10	S5601_012_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				54.97	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	19	19	19				19	19	19				19		19
S5601	012	0		29	10	S5601_012_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				48.36	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	25	25	25				25	25	25				25		25
S5601	012	0		29	10	S5601_012_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				491.82	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	014	0		29	10	S5601_014_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	014	0		29	10	S5601_014_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	014	0		29	10	S5601_014_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.59	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	18	18	18				18	18	18				18		18
S5601	014	0		29	10	S5601_014_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				42.86	33	33	33																		33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	014	0		29	10	S5601_014_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				262.91	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	016	0		29	10	S5601_016_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	016	0		29	10	S5601_016_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	016	0		29	10	S5601_016_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.33	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	18	18	18				18	18	18				18		18
S5601	016	0		29	10	S5601_016_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				41.75	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	016	0		29	10	S5601_016_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				268.48	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	018	0		29	10	S5601_018_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	018	0		29	10	S5601_018_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	018	0		29	10	S5601_018_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.43	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	18	18	18				18	18	18				18		18
S5601	018	0		29	10	S5601_018_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				42.76	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	25	25	25				25	25	25				25		25
S5601	018	0		29	10	S5601_018_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				271.26	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	020	0		29	10	S5601_020_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	020	0		29	10	S5601_020_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	020	0		29	10	S5601_020_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.06	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	18	18	18				18	18	18				18		18
S5601	020	0		29	10	S5601_020_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				38.90	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	25	25	25				25	25	25				25		25
S5601	020	0		29	10	S5601_020_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				267.89	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	022	0		29	10	S5601_022_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	022	0		29	10	S5601_022_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	022	0		29	10	S5601_022_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.46	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		35.00	18	18	18				18	18	18				18		18
S5601	022	0		29	10	S5601_022_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				42.74	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	25	25	25				25	25	25				25		25
S5601	022	0		29	10	S5601_022_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				272.02	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	024	0		29	10	S5601_024_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	024	0		29	10	S5601_024_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	024	0		29	10	S5601_024_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				17.59	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	18	18	18				18	18	18				18		18
S5601	024	0		29	10	S5601_024_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				38.68	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	25	25	25				25	25	25				25		25
S5601	024	0		29	10	S5601_024_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				264.07	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	026	0		29	10	S5601_026_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	026	0		29	10	S5601_026_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	026	0		29	10	S5601_026_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				19.65	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	18	18	18				18	18	18				18		18
S5601	026	0		29	10	S5601_026_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				43.80	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	25	25	25				25	25	25				25		25
S5601	026	0		29	10	S5601_026_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				264.49	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	028	0		29	10	S5601_028_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	028	0		29	10	S5601_028_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	028	0		29	10	S5601_028_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				19.00	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	18	18	18				18	18	18				18		18
S5601	028	0		29	10	S5601_028_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				42.61	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	25	25	25				25	25	25				25		25
S5601	028	0		29	10	S5601_028_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				266.31	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	030	0		29	10	S5601_030_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	030	0		29	10	S5601_030_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				52.76	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	19	19	19				19	19	19				19		19
S5601	030	0		29	10	S5601_030_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				44.52	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	25	25	25				25	25	25				25		25
S5601	030	0		29	10	S5601_030_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				451.88	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	032	0		29	10	S5601_032_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	032	0		29	10	S5601_032_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				53.26	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	19	19	19				19	19	19				19		19
S5601	032	0		29	10	S5601_032_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				48.17	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	25	25	25				25	25	25				25		25
S5601	032	0		29	10	S5601_032_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				467.51	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	034	0		29	10	S5601_034_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	034	0		29	10	S5601_034_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	034	0		29	10	S5601_034_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				19.19	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	18	18	18				18	18	18				18		18
S5601	034	0		29	10	S5601_034_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				41.37	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	25	25	25				25	25	25				25		25
S5601	034	0		29	10	S5601_034_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				264.29	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	036	0		29	10	S5601_036_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	036	0		29	10	S5601_036_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	036	0		29	10	S5601_036_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				16.52	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	18	18	18				18	18	18				18		18
S5601	036	0		29	10	S5601_036_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				38.47	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	036	0		29	10	S5601_036_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				267.34	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	038	0		29	10	S5601_038_0	1			Preferred Generic	2	11	1	2	1	1	111		10			1	30	60	90				1	2								10	31	0.00	0.00	0.00																																						0.00			0.00		0.00						0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5601	038	0		29	10	S5601_038_0	1			Generic	2	01	1	2	2	1	111		10			1	30	60	90				1	2								10	31	7.00	14.00	21.00																																						7.00			7.00		0.23						0.23	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5601	038	0		29	10	S5601_038_0	1			Preferred Brand	2	11	1	1	3	1	111		10			1	30	60	90				1	2								10	31				17.84	18	18	18																																				18		18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	18	18	18										18		18
S5601	038	0		29	10	S5601_038_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10			1	30	60	90				1	2								10	31				39.71	33	33	33																																				33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00										35.00		35.00	25	25	25										25		25
S5601	038	0		29	10	S5601_038_0	1			Specialty Tier	2	11	1	1	5	1	010		10			1	30															10	31				258.48	25																																						25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
S5601	040	0		29	10	S5601_040_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	040	0		29	10	S5601_040_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	040	0		29	10	S5601_040_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.07	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	18	18	18				18	18	18				18		18
S5601	040	0		29	10	S5601_040_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				37.77	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	25	25	25				25	25	25				25		25
S5601	040	0		29	10	S5601_040_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				261.47	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	042	0		29	10	S5601_042_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	042	0		29	10	S5601_042_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				57.33	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	19	19	19				19	19	19				19		19
S5601	042	0		29	10	S5601_042_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				46.23	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	25	25	25				25	25	25				25		25
S5601	042	0		29	10	S5601_042_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				468.20	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	044	0		29	10	S5601_044_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	044	0		29	10	S5601_044_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	044	0		29	10	S5601_044_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.12	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	18	18	18				18	18	18				18		18
S5601	044	0		29	10	S5601_044_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				39.72	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	25	25	25				25	25	25				25		25
S5601	044	0		29	10	S5601_044_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				263.53	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	048	0		29	10	S5601_048_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	048	0		29	10	S5601_048_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	048	0		29	10	S5601_048_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				16.51	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	18	18	18				18	18	18				18		18
S5601	048	0		29	10	S5601_048_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				38.95	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	25	25	25				25	25	25				25		25
S5601	048	0		29	10	S5601_048_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				261.34	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	050	0		29	10	S5601_050_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	050	0		29	10	S5601_050_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				53.28	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	19	19	19				19	19	19				19		19
S5601	050	0		29	10	S5601_050_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				44.09	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	25	25	25				25	25	25				25		25
S5601	050	0		29	10	S5601_050_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				467.82	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	052	0		29	10	S5601_052_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	052	0		29	10	S5601_052_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	052	0		29	10	S5601_052_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				20.20	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	18	18	18				18	18	18				18		18
S5601	052	0		29	10	S5601_052_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				43.69	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	25	25	25				25	25	25				25		25
S5601	052	0		29	10	S5601_052_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				276.02	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	054	0		29	10	S5601_054_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	054	0		29	10	S5601_054_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	054	0		29	10	S5601_054_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				18.71	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	18	18	18				18	18	18				18		18
S5601	054	0		29	10	S5601_054_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				44.57	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	25	25	25				25	25	25				25		25
S5601	054	0		29	10	S5601_054_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				275.11	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	056	0		29	10	S5601_056_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	056	0		29	10	S5601_056_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	056	0		29	10	S5601_056_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				19.70	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	18	18	18				18	18	18				18		18
S5601	056	0		29	10	S5601_056_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				44.71	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	25	25	25				25	25	25				25		25
S5601	056	0		29	10	S5601_056_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				275.17	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	058	0		29	10	S5601_058_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	058	0		29	10	S5601_058_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	058	0		29	10	S5601_058_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				20.26	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	18	18	18				18	18	18				18		18
S5601	058	0		29	10	S5601_058_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				43.67	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	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	058	0		29	10	S5601_058_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				271.30	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	060	0		29	10	S5601_060_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	060	0		29	10	S5601_060_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	060	0		29	10	S5601_060_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				17.70	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	18	18	18				18	18	18				18		18
S5601	060	0		29	10	S5601_060_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				41.94	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	25	25	25				25	25	25				25		25
S5601	060	0		29	10	S5601_060_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				266.24	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	062	0		29	10	S5601_062_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	062	0		29	10	S5601_062_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				53.88	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	19	19	19				19	19	19				19		19
S5601	062	0		29	10	S5601_062_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				49.65	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	25	25	25				25	25	25				25		25
S5601	062	0		29	10	S5601_062_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				482.27	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	064	0		29	10	S5601_064_0	2			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	064	0		29	10	S5601_064_0	2			Generic	2	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 Drug, Specialty Tier																														
S5601	064	0		29	10	S5601_064_0	2			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				21.33	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	18	18	18				18	18	18				18		18
S5601	064	0		29	10	S5601_064_0	2			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				47.51	33	33	33																		33	33	33																33		33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00				35.00	70.00	105.00				35.00		35.00	25	25	25				25	25	25				25		25
S5601	064	0		29	10	S5601_064_0	2			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				277.47	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	066	0		29	10	S5601_066_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	066	0		29	10	S5601_066_0	1			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	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				62.41	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	19	19	19				19	19	19				19		19
S5601	066	0		29	10	S5601_066_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				59.78	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	25	25	25				25	25	25				25		25
S5601	066	0		29	10	S5601_066_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				530.71	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5601	068	0		29	10	S5601_068_0	1			Preferred Generic	2	11	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 Drug, Specialty Tier																														
S5601	068	0		29	10	S5601_068_0	1			Generic	2	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 Drug, Specialty Tier																														
S5601	068	0		29	10	S5601_068_0	1			Preferred Brand	2	11	1	1	3	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				21.12	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	18	18	18				18	18	18				18		18
S5601	068	0		29	10	S5601_068_0	1			Non-Preferred Drug	2	11	1	1	4	1	111		10	111		1	30	60	90				1	2	30	60	90					10	31				48.98	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	25	25	25				25	25	25				25		25
S5601	068	0		29	10	S5601_068_0	1			Specialty Tier	2	11	1	1	5	1	010		10	010		1	30								30							10	31				270.82	25																				25																		25		25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00						35.00		35.00	25						25						25		25
S5617	003	0		29	10	S5617_003_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.74	10	10	10				0.14	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	003	0		29	10	S5617_003_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											2.15	15	15	15				0.67	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
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											36.43	25	25	25				41.24	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											32.61	30	30	30				33.72	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5617	008	0		29	10	S5617_008_0	5			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	008	0		29	10	S5617_008_0	5			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	008	0		29	10	S5617_008_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.67	23	23	23				38.41	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	008	0		29	10	S5617_008_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.50	33	33	33				33.89	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	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	008	0		29	10	S5617_008_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	013	0		29	10	S5617_013_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.63	10	10	10				0.13	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	013	0		29	10	S5617_013_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.83	15	15	15				0.57	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	013	0		29	10	S5617_013_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.01	25	25	25				41.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	013	0		29	10	S5617_013_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											37.73	29	29	29				35.40	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	013	0		29	10	S5617_013_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	25			25			25			25			25		25
S5617	018	0		29	10	S5617_018_0	4			Preferred Generic	2	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	018	0		29	10	S5617_018_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	018	0		29	10	S5617_018_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.84	21	21	21				33.69	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	21	21	21	20	20	20	21	21	21	20	20	20	21		21
S5617	018	0		29	10	S5617_018_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											40.10	30	30	30				38.59	27	27	27										30	30	30				27	27	27			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	018	0		29	10	S5617_018_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	25			25			25			25			25		25
S5617	068	0		29	10	S5617_068_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	068	0		29	10	S5617_068_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	068	0		29	10	S5617_068_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.49	23	23	23				37.18	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	068	0		29	10	S5617_068_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											31.92	34	34	34				29.65	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	068	0		29	10	S5617_068_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	25			25			25			25			25		25
S5617	088	0		29	10	S5617_088_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	088	0		29	10	S5617_088_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	088	0		29	10	S5617_088_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.76	21	21	21				34.95	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	21	21	21	20	20	20	21	21	21	20	20	20	21		21
S5617	088	0		29	10	S5617_088_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											33.81	32	32	32				30.62	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	088	0		29	10	S5617_088_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	25			25			25			25			25		25
S5617	103	0		29	10	S5617_103_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	103	0		29	10	S5617_103_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	103	0		29	10	S5617_103_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											31.71	21	21	21				36.04	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	21	21	21	20	20	20	21	21	21	20	20	20	21		21
S5617	103	0		29	10	S5617_103_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											33.60	31	31	31				33.43	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	103	0		29	10	S5617_103_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	25			25			25			25			25		25
S5617	108	0		29	10	S5617_108_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	108	0		29	10	S5617_108_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	108	0		29	10	S5617_108_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.01	22	22	22				37.27	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	22	22	22	21	21	21	22	22	22	21	21	21	22		22
S5617	108	0		29	10	S5617_108_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											34.45	32	32	32				29.64	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	108	0		29	10	S5617_108_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	25			25			25			25			25		25
S5617	113	0		29	10	S5617_113_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	113	0		29	10	S5617_113_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	113	0		29	10	S5617_113_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.24	22	22	22				35.60	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	22	22	22	20	20	20	22	22	22	20	20	20	22		22
S5617	113	0		29	10	S5617_113_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											39.20	30	30	30				33.99	29	29	29										30	30	30				29	29	29			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	113	0		29	10	S5617_113_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	25			25			25			25			25		25
S5617	118	0		29	10	S5617_118_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.61	10	10	10				0.14	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	118	0		29	10	S5617_118_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.85	15	15	15				0.63	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	118	0		29	10	S5617_118_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											32.54	25	25	25				36.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	118	0		29	10	S5617_118_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											30.51	31	31	31				29.57	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	118	0		29	10	S5617_118_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	25			25			25			25			25		25
S5617	123	0		29	10	S5617_123_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	123	0		29	10	S5617_123_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	123	0		29	10	S5617_123_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.98	23	23	23				37.94	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	123	0		29	10	S5617_123_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											31.09	32	32	32				27.54	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	123	0		29	10	S5617_123_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	25			25			25			25			25		25
S5617	128	0		29	10	S5617_128_0	5			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.64	10	10	10				0.15	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	128	0		29	10	S5617_128_0	5			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.96	15	15	15				0.69	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	128	0		29	10	S5617_128_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											40.36	25	25	25				40.54	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	128	0		29	10	S5617_128_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.50	30	30	30				26.66	29	29	29										30	30	30				29	29	29			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	128	0		29	10	S5617_128_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	133	0		29	10	S5617_133_0	5			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	133	0		29	10	S5617_133_0	5			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	133	0		29	10	S5617_133_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.14	21	21	21				36.23	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	21	21	21	20	20	20	21	21	21	20	20	20	21		21
S5617	133	0		29	10	S5617_133_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.51	31	31	31				35.94	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	133	0		29	10	S5617_133_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	138	0		29	10	S5617_138_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.47	10	10	10				0.14	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	138	0		29	10	S5617_138_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.52	15	15	15				0.62	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	138	0		29	10	S5617_138_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											41.30	25	25	25				40.59	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	138	0		29	10	S5617_138_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											36.97	30	30	30				35.56	29	29	29										30	30	30				29	29	29			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	138	0		29	10	S5617_138_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	25			25			25			25			25		25
S5617	143	0		29	10	S5617_143_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	143	0		29	10	S5617_143_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	143	0		29	10	S5617_143_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											39.44	22	22	22				40.09	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	22	22	22	20	20	20	22	22	22	20	20	20	22		22
S5617	143	0		29	10	S5617_143_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											45.83	30	30	30				43.68	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	143	0		29	10	S5617_143_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	25			25			25			25			25		25
S5617	148	0		29	10	S5617_148_0	5			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.61	10	10	10				0.12	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	148	0		29	10	S5617_148_0	5			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.83	15	15	15				0.59	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	148	0		29	10	S5617_148_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.56	25	25	25				33.63	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	25	25	25	24	24	24	25	25	25	24	24	24	25		25
S5617	148	0		29	10	S5617_148_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.34	31	31	31				29.32	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	148	0		29	10	S5617_148_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	153	0		29	10	S5617_153_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	153	0		29	10	S5617_153_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	153	0		29	10	S5617_153_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											32.30	22	22	22				36.03	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	22	22	22	21	21	21	22	22	22	21	21	21	22		22
S5617	153	0		29	10	S5617_153_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											34.00	31	31	31				30.43	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	153	0		29	10	S5617_153_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	25			25			25			25			25		25
S5617	158	0		29	10	S5617_158_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.46	10	10	10				0.13	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	158	0		29	10	S5617_158_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.48	15	15	15				0.57	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	158	0		29	10	S5617_158_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.71	25	25	25				39.91	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	158	0		29	10	S5617_158_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											37.64	29	29	29				36.10	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	158	0		29	10	S5617_158_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	25			25			25			25			25		25
S5617	214	0		29	10	S5617_214_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	214	0		29	10	S5617_214_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	214	0		29	10	S5617_214_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.82	23	23	23				36.75	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	23	23	23	22	22	22	23	23	23	22	22	22	23		23
S5617	214	0		29	10	S5617_214_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											33.28	32	32	32				29.94	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	214	0		29	10	S5617_214_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	25			25			25			25			25		25
S5617	215	0		29	10	S5617_215_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	215	0		29	10	S5617_215_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	215	0		29	10	S5617_215_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.63	23	23	23				38.76	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	215	0		29	10	S5617_215_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											31.70	32	32	32				30.51	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	215	0		29	10	S5617_215_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	25			25			25			25			25		25
S5617	216	0		29	10	S5617_216_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	216	0		29	10	S5617_216_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	216	0		29	10	S5617_216_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.10	23	23	23				37.73	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	23	23	23	22	22	22	23	23	23	22	22	22	23		23
S5617	216	0		29	10	S5617_216_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											32.89	33	33	33				32.50	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	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	216	0		29	10	S5617_216_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	25			25			25			25			25		25
S5617	217	0		29	10	S5617_217_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	217	0		29	10	S5617_217_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	217	0		29	10	S5617_217_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.75	23	23	23				36.55	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	23	23	23	22	22	22	23	23	23	22	22	22	23		23
S5617	217	0		29	10	S5617_217_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											33.57	33	33	33				30.03	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	217	0		29	10	S5617_217_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	25			25			25			25			25		25
S5617	218	0		29	10	S5617_218_0	5			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	218	0		29	10	S5617_218_0	5			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	218	0		29	10	S5617_218_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.60	23	23	23				39.54	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	218	0		29	10	S5617_218_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											38.38	31	31	31				36.79	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	218	0		29	10	S5617_218_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	219	0		29	10	S5617_219_0	5			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	219	0		29	10	S5617_219_0	5			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	219	0		29	10	S5617_219_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											36.02	23	23	23				37.07	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	219	0		29	10	S5617_219_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.54	31	31	31				35.77	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	219	0		29	10	S5617_219_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	220	0		29	10	S5617_220_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	220	0		29	10	S5617_220_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	220	0		29	10	S5617_220_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.53	23	23	23				37.04	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	23	23	23	22	22	22	23	23	23	22	22	22	23		23
S5617	220	0		29	10	S5617_220_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											32.56	34	34	34				28.92	32	32	32										34	34	34				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	220	0		29	10	S5617_220_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	25			25			25			25			25		25
S5617	221	0		29	10	S5617_221_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.59	10	10	10				0.14	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	221	0		29	10	S5617_221_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.71	15	15	15				0.61	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	221	0		29	10	S5617_221_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.84	25	25	25				41.01	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	221	0		29	10	S5617_221_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											32.91	31	31	31				33.83	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	221	0		29	10	S5617_221_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	25			25			25			25			25		25
S5617	222	0		29	10	S5617_222_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	222	0		29	10	S5617_222_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	222	0		29	10	S5617_222_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.62	22	22	22				37.55	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	22	22	22	20	20	20	22	22	22	20	20	20	22		22
S5617	222	0		29	10	S5617_222_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											34.47	33	33	33				35.67	30	30	30										33	33	33				30	30	30			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	222	0		29	10	S5617_222_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	25			25			25			25			25		25
S5617	223	0		29	10	S5617_223_0	4			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.69	10	10	10				0.14	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	223	0		29	10	S5617_223_0	4			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.81	14	14	14				0.69	10	10	10										14	14	14				10	10	10			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	70.00	105.00	35.00	70.00	105.00	35.00		35.00	14	14	14	10	10	10	14	14	14	10	10	10	14		14
S5617	223	0		29	10	S5617_223_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.75	25	25	25				39.32	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	223	0		29	10	S5617_223_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											31.50	31	31	31				33.47	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	223	0		29	10	S5617_223_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	25			25			25			25			25		25
S5617	224	0		29	10	S5617_224_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	224	0		29	10	S5617_224_0	4			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	224	0		29	10	S5617_224_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.65	23	23	23				39.59	21	21	21										23	23	23				21	21	21			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	23	23	23	21	21	21	23	23	23	21	21	21	23		23
S5617	224	0		29	10	S5617_224_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											35.33	33	33	33				36.74	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	224	0		29	10	S5617_224_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	25			25			25			25			25		25
S5617	225	0		29	10	S5617_225_0	5			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.72	10	10	10				0.16	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	225	0		29	10	S5617_225_0	5			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											2.06	15	15	15				0.70	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	225	0		29	10	S5617_225_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											35.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	225	0		29	10	S5617_225_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.63	29	29	29				28.17	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	225	0		29	10	S5617_225_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	226	0		29	10	S5617_226_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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	226	0		29	10	S5617_226_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					2.00	4.00	6.00											11.00	22.00	33.00				2.00	4.00	2.00				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	2.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	226	0		29	10	S5617_226_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											34.27	22	22	22				39.60	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	22	22	22	21	21	21	22	22	22	21	21	21	22		22
S5617	226	0		29	10	S5617_226_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											29.02	31	31	31				28.05	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	226	0		29	10	S5617_226_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	25			25			25			25			25		25
S5617	227	0		29	10	S5617_227_0	5			Preferred Generic	2	01	1	1	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											0.77	10	10	10				0.15	5	5	5										10	10	10				5	5	5			10			10								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	10	10	10	5	5	5	10	10	10	5	5	5	10		10
S5617	227	0		29	10	S5617_227_0	5			Generic	2	01	1	1	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											1.91	15	15	15				0.64	10	10	10										15	15	15				10	10	10			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	15	15	15	10	10	10	15	15	15	10	10	10	15		15
S5617	227	0		29	10	S5617_227_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.04	25	25	25				44.49	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	227	0		29	10	S5617_227_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											33.38	29	29	29				35.48	29	29	29										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	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	227	0		29	10	S5617_227_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	348	0		29	10	S5617_348_0	5			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	348	0		29	10	S5617_348_0	5			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	2.00				12.00				12.00			0.40	0.07		0.40	0.07	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	2.00	4.00	6.00	12.00	24.00	36.00	2.00	4.00	2.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	348	0		29	10	S5617_348_0	5			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											45.65	23	23	23				46.20	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	23	23	23	22	22	22	23	23	23	22	22	22	23		23
S5617	348	0		29	10	S5617_348_0	5			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											42.16	40	40	40				33.52	34	34	34										40	40	40				34	34	34			40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	348	0		29	10	S5617_348_0	5			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	353	0		29	10	S5617_353_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	353	0		29	10	S5617_353_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	353	0		29	10	S5617_353_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											23.40	17	17	17				23.79	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	17	17	17	17	17	17	17	17	17	17	17	17	17		17
S5617	353	0		29	10	S5617_353_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											50.79	30	30	30				37.48	29	29	29										30	30	30				29	29	29			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	353	0		29	10	S5617_353_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	354	0		29	10	S5617_354_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	354	0		29	10	S5617_354_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	354	0		29	10	S5617_354_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											23.77	17	17	17				24.15	16	16	16										17	17	17				16	16	16			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	17	17	17	16	16	16	17	17	17	16	16	16	17		17
S5617	354	0		29	10	S5617_354_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											38.85	30	30	30				38.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	354	0		29	10	S5617_354_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	355	0		29	10	S5617_355_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	355	0		29	10	S5617_355_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	355	0		29	10	S5617_355_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											21.93	20	20	20				21.27	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	355	0		29	10	S5617_355_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											48.40	34	34	34				35.90	32	32	32										34	34	34				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	355	0		29	10	S5617_355_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	356	0		29	10	S5617_356_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	356	0		29	10	S5617_356_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	356	0		29	10	S5617_356_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.29	20	20	20				24.09	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	356	0		29	10	S5617_356_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											44.87	32	32	32				36.74	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	356	0		29	10	S5617_356_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	358	0		29	10	S5617_358_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	358	0		29	10	S5617_358_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	358	0		29	10	S5617_358_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											23.07	20	20	20				18.90	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	358	0		29	10	S5617_358_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											43.43	32	32	32				34.35	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	358	0		29	10	S5617_358_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	359	0		29	10	S5617_359_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	359	0		29	10	S5617_359_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	359	0		29	10	S5617_359_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											25.82	19	19	19				24.22	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	19	19	19	17	17	17	19	19	19	17	17	17	19		19
S5617	359	0		29	10	S5617_359_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											38.98	30	30	30				34.16	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	359	0		29	10	S5617_359_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	360	0		29	10	S5617_360_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	360	0		29	10	S5617_360_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	360	0		29	10	S5617_360_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.82	20	20	20				23.89	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	360	0		29	10	S5617_360_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											41.67	32	32	32				36.30	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	360	0		29	10	S5617_360_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	362	0		29	10	S5617_362_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	362	0		29	10	S5617_362_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	362	0		29	10	S5617_362_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											22.02	19	19	19				19.07	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	19	19	19	17	17	17	19	19	19	17	17	17	19		19
S5617	362	0		29	10	S5617_362_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											45.75	33	33	33				34.34	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	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	362	0		29	10	S5617_362_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	363	0		29	10	S5617_363_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	363	0		29	10	S5617_363_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	363	0		29	10	S5617_363_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.59	20	20	20				21.85	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	363	0		29	10	S5617_363_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											45.18	33	33	33				38.90	32	32	32										33	33	33				32	32	32			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	363	0		29	10	S5617_363_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											25.67	19	19	19				24.61	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	19	19	19	17	17	17	19	19	19	17	17	17	19		19
S5617	364	0		29	10	S5617_364_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											46.01	32	32	32				37.13	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5617	365	0		29	10	S5617_365_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	365	0		29	10	S5617_365_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	365	0		29	10	S5617_365_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											25.88	20	20	20				25.02	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	365	0		29	10	S5617_365_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											34.83	30	30	30				34.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	365	0		29	10	S5617_365_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	366	0		29	10	S5617_366_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	366	0		29	10	S5617_366_0	5			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	0.42	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	366	0		29	10	S5617_366_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.22	20	20	20				24.24	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	366	0		29	10	S5617_366_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											49.62	34	34	34				39.94	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	366	0		29	10	S5617_366_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											31.83	22	22	22				25.15	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	22	22	22	17	17	17	22	22	22	17	17	17	22		22
S5617	367	0		29	10	S5617_367_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											38.67	32	32	32				36.62	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											23.73	20	20	20				23.87	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	368	0		29	10	S5617_368_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											35.90	32	32	32				30.94	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5617	369	0		29	10	S5617_369_0	6			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					0.00	0.00	0.00											6.00	12.00	18.00				0.00	0.00	0.00				6.00				6.00			0.20	0.00		0.20	0.00	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	369	0		29	10	S5617_369_0	6			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	369	0		29	10	S5617_369_0	6			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.71	21	21	21				24.99	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	21	21	21	17	17	17	21	21	21	17	17	17	21		21
S5617	369	0		29	10	S5617_369_0	6			Non-Preferred Drug	4	11	3	1	4	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											37.89	35	35	35				26.96	31	31	31										35	35	35				31	31	31			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	369	0		29	10	S5617_369_0	6			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	370	0		29	10	S5617_370_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	370	0		29	10	S5617_370_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	370	0		29	10	S5617_370_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											21.17	19	19	19				20.04	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	19	19	19	17	17	17	19	19	19	17	17	17	19		19
S5617	370	0		29	10	S5617_370_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											42.87	30	30	30				34.92	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	370	0		29	10	S5617_370_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	371	0		29	10	S5617_371_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	371	0		29	10	S5617_371_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	371	0		29	10	S5617_371_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											23.35	20	20	20				23.93	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	371	0		29	10	S5617_371_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											36.66	31	31	31				36.17	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	371	0		29	10	S5617_371_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											21.52	20	20	20				21.34	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	372	0		29	10	S5617_372_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											43.63	32	32	32				34.33	30	30	30										32	32	32				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5617	373	0		29	10	S5617_373_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	373	0		29	10	S5617_373_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	373	0		29	10	S5617_373_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.68	20	20	20				26.23	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	373	0		29	10	S5617_373_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											41.10	33	33	33				32.87	30	30	30										33	33	33				30	30	30			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	373	0		29	10	S5617_373_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	375	0		29	10	S5617_375_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	375	0		29	10	S5617_375_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	375	0		29	10	S5617_375_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											28.93	20	20	20				22.87	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	375	0		29	10	S5617_375_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											39.49	32	32	32				35.33	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	375	0		29	10	S5617_375_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	377	0		29	10	S5617_377_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	377	0		29	10	S5617_377_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	377	0		29	10	S5617_377_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											27.29	20	20	20				24.71	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	377	0		29	10	S5617_377_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											42.34	32	32	32				39.21	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	377	0		29	10	S5617_377_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											19.50	20	20	20				21.83	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	378	0		29	10	S5617_378_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											48.82	32	32	32				38.27	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5617	379	0		29	10	S5617_379_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	379	0		29	10	S5617_379_0	5			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					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	379	0		29	10	S5617_379_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											29.08	20	20	20				26.28	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	379	0		29	10	S5617_379_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											38.51	33	33	33				33.67	30	30	30										33	33	33				30	30	30			33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	379	0		29	10	S5617_379_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	380	0		29	10	S5617_380_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	380	0		29	10	S5617_380_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	380	0		29	10	S5617_380_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											24.33	20	20	20				21.22	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	20	20	20	16	16	16	20	20	20	16	16	16	20		20
S5617	380	0		29	10	S5617_380_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											43.73	31	31	31				38.09	30	30	30										31	31	31				30	30	30			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	380	0		29	10	S5617_380_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5617	381	0		29	10	S5617_381_0	5			Preferred Generic	4	01	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5617	381	0		29	10	S5617_381_0	5			Generic	4	01	3	2	2	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	381	0		29	10	S5617_381_0	5			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	2	2				30	60	90	30		31											22.33	20	20	20				20.33	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	20	20	20	17	17	17	20	20	20	17	17	17	20		20
S5617	381	0		29	10	S5617_381_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											45.48	32	32	32				34.81	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5617	381	0		29	10	S5617_381_0	5			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												25							25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								11.00	22.00	33.00					5.00	10.00	15.00											11.00	22.00	33.00				5.00	10.00	3.00				11.00				11.00			0.37	0.17		0.37	0.17	0.35	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	11.00	22.00	33.00	5.00	10.00	15.00	11.00	22.00	33.00	5.00	10.00	3.00	11.00		11.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											22.19	19	19	19				21.91	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	19	19	19	17	17	17	19	19	19	17	17	17	19		19
S5617	382	0		29	10	S5617_382_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											42.58	30	30	30				34.99	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
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								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	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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								12.00	24.00	36.00					5.00	10.00	15.00											12.00	24.00	36.00				5.00	10.00	3.00				12.00				12.00			0.40	0.17		0.40	0.17	0.39	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	12.00	24.00	36.00	5.00	10.00	15.00	12.00	24.00	36.00	5.00	10.00	3.00	12.00		12.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											31.85	21	21	21				27.90	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	21	21	21	17	17	17	21	21	21	17	17	17	21		21
S5617	385	0		29	10	S5617_385_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											53.54	33	33	33				41.09	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	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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	25			25			25			25			25		25
S5715	001	0		29	10	S5715_001_0	4			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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	001	0		29	10	S5715_001_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	001	0		29	10	S5715_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											38.68	21	21	21				35.11	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	21	21	21	18	18	18	21	21	21	18	18	18	21		21
S5715	001	0		29	10	S5715_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											68.89	36	36	36				70.27	32	32	32										36	36	36				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	001	0		29	10	S5715_001_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											565.27	25						574.05	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	005	0		29	10	S5715_005_0	4			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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	005	0		29	10	S5715_005_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	005	0		29	10	S5715_005_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											38.29	21	21	21				35.58	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	21	21	21	18	18	18	21	21	21	18	18	18	21		21
S5715	005	0		29	10	S5715_005_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											71.30	34	34	34				71.53	32	32	32										34	34	34				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	005	0		29	10	S5715_005_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											593.09	25						539.01	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	010	0		29	10	S5715_010_0	4			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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	010	0		29	10	S5715_010_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								6.00	12.00	18.00					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	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	010	0		29	10	S5715_010_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											35.56	20	20	20				34.61	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	20	20	20	18	18	18	20	20	20	18	18	18	20		20
S5715	010	0		29	10	S5715_010_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											71.27	34	34	34				72.92	32	32	32										34	34	34				32	32	32			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	010	0		29	10	S5715_010_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											635.63	25						589.52	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	012	0		29	10	S5715_012_0	4			Preferred Generic	2	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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	012	0		29	10	S5715_012_0	4			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	012	0		29	10	S5715_012_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											37.09	22	22	22				34.59	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	22	22	22	20	20	20	22	22	22	20	20	20	22		22
S5715	012	0		29	10	S5715_012_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											56.37	45	45	45				55.89	43	43	43										45	45	45				43	43	43			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	012	0		29	10	S5715_012_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											656.57	25						550.77	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								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	013	0		29	10	S5715_013_0	5			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											33.67	20	20	20				33.22	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	20	20	20	18	18	18	20	20	20	18	18	18	20		20
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											74.02	42	42	42				72.22	40	40	40										42	42	42				40	40	40			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											590.95	25						571.20	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	014	0		29	10	S5715_014_0	4			Preferred Generic	2	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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	014	0		29	10	S5715_014_0	4			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	014	0		29	10	S5715_014_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											36.24	21	21	21				34.34	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	21	21	21	19	19	19	21	21	21	19	19	19	21		21
S5715	014	0		29	10	S5715_014_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											55.60	45	45	45				52.30	42	42	42										45	45	45				42	42	42			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	014	0		29	10	S5715_014_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											583.87	25						563.32	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	015	0		29	10	S5715_015_0	4			Preferred Generic	2	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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	015	0		29	10	S5715_015_0	4			Generic	2	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					5.00	10.00	15.00											10.00	20.00	30.00				5.00	10.00	15.00				10.00				10.00			0.33	0.17		0.33	0.17	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00	20.00	30.00	5.00	10.00	15.00	10.00	20.00	30.00	5.00	10.00	15.00	10.00		10.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	015	0		29	10	S5715_015_0	4			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											25.09	18	18	18				26.73	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	18	18	18	16	16	16	18	18	18	16	16	16	18		18
S5715	015	0		29	10	S5715_015_0	4			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											50.11	42	42	42				54.33	40	40	40										42	42	42				40	40	40			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	015	0		29	10	S5715_015_0	4			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											473.74	25						483.33	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5715	020	0		29	10	S5715_020_0	4			Preferred Generic	4	11	1	2	1	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								5.00	10.00	15.00					0.00	0.00	0.00											5.00	10.00	15.00				0.00	0.00	0.00				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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	020	0		29	10	S5715_020_0	4			Generic	4	11	1	2	2	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31								10.00	20.00	30.00					4.00	8.00	12.00											10.00	20.00	30.00				4.00	8.00	12.00				10.00				10.00			0.33	0.13		0.33	0.13	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	020	0		29	10	S5715_020_0	4			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											34.73	16	16	16				30.12	14	14	14										16	16	16				14	14	14			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	16	16	16	14	14	14	16	16	16	14	14	14	16		16
S5715	020	0		29	10	S5715_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											44.29	35	35	35				41.78	33	33	33										35	35	35				33	33	33			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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5715	020	0		29	10	S5715_020_0	4			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31											606.93	25						599.50	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					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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					2.00	4.00	6.00											9.00	18.00	27.00				2.00	4.00	6.00				9.00				9.00			0.30	0.07		0.30	0.07	0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	9.00	18.00	27.00	2.00	4.00	6.00	9.00	18.00	27.00	2.00	4.00	6.00	9.00		9.00	25	25	25	20	20	20	25	25	25	20	20	20	25		25
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											36.88	25	25	25				26.65	18	18	18										25	25	25				18	18	18			25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	18	18	18	25	25	25	18	18	18	25		25
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											71.74	50	50	50				57.50	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											592.38	25						608.66	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5726	014	0		29	10	S5726_014_0	1			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5726	014	0		29	10	S5726_014_0	1			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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
S5726	014	0		29	10	S5726_014_0	1			Preferred Brand	4	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											43.64	25	25	25				34.70	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	25	25	25	20	20	20	25	25	25	20	20	20	25		25
S5726	014	0		29	10	S5726_014_0	1			Non-Preferred Drug	4	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		34											97.53	50	50	50				77.56	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5726	014	0		29	10	S5726_014_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		34											799.86	33						869.52	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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					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	0.21	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	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	25	25	25	0	0	0	25	25	25	0	0	0	25		25
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											66.45	25	25	25				54.12	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	25	25	25	20	20	20	25	25	25	20	20	20	25		25
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											93.72	50	50	50				60.61	30	30	30										50	50	50				30	30	30			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00	70.00	105.00	35.00		35.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
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											775.62	25						1009.57	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5743	001	0		29	10	S5743_001_0	3			Preferred Generic	2	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	5.00	10.00	15.00	0.00	0.00	0.00	5.00	10.00	15.00	0.00	0.00	0.00	5.00		5.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5743	001	0		29	10	S5743_001_0	3			Generic	2	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					1.00	2.00	3.00											7.00	14.00	21.00				1.00	2.00	3.00				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	3.00	7.00		7.00	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5743	001	0		29	10	S5743_001_0	3			Preferred Brand	2	11	1	1	3	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											39.38	25	25	25				33.10	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	25	25	25	22	22	22	25	25	25	22	22	22	25		25
S5743	001	0		29	10	S5743_001_0	3			Non-Preferred Drug	2	11	1	1	4	1		111	01		111	1				30	60	90	1	2				30	60	90	30		31											70.70	50	50	50				59.26	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	25	25	25	25	25	25	25	25	25	25	25	25	25		25
S5743	001	0		29	10	S5743_001_0	3			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30								30			30		31											576.86	25						584.56	25												25						25					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5795	002	0		29	10	S5795_002_0	3			Preferred Generic	4	11	1	2	1	1	110		01			1	30		100				1	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																														
S5795	002	0		29	10	S5795_002_0	3			Generic	4	11	1	2	2	1	110		01			1	30		100				1	2							30		31	5.00		15.00																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5795	002	0		29	10	S5795_002_0	3			Preferred Brand	4	11	1	1	3	1	110		01			1	30		100				1	2							30		31				21.63	20		20																																			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	20		20										20		20
S5795	002	0		29	10	S5795_002_0	3			Non-Preferred Drug	4	11	1	1	4	1	110		01			1	30		100				1	2							30		31				70.97	34		34																																			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
S5795	002	0		29	10	S5795_002_0	3			Specialty Tier	4	11	1	1	5	1	010		01			1	30														30		31				703.43	33																																					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
S5795	003	0		29	10	S5795_003_0	3			Preferred Generic	3	11	1	2	1	1	110		01			1	30		100				1	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																														
S5795	003	0		29	10	S5795_003_0	3			Generic	3	11	1	2	2	1	110		01			1	30		100				1	2							30		31	5.00		15.00																																					5.00				5.00		0.17						0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5795	003	0		29	10	S5795_003_0	3			Preferred Brand	3	11	1	1	3	1	110		01			1	30		100				2	2							30		31				27.87	19		19																																			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	19		19										19		19
S5795	003	0		29	10	S5795_003_0	3			Non-Preferred Drug	3	11	1	1	4	1	110		01			1	30		100				1	2							30		31				68.50	34		34																																			34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00										35.00		35.00	25		25										25		25
S5795	003	0		29	10	S5795_003_0	3			Specialty Tier	3	11	1	1	5	1	010		01			1	30														30		31				697.90	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
S5884	101	0		29	10	S5884_101_0	4			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	0		0				0		0	0		0	0		0
S5884	101	0		29	10	S5884_101_0	4			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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	101	0		29	10	S5884_101_0	4			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	101	0		29	10	S5884_101_0	4			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	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	25						25			25			25		25
S5884	101	0		29	10	S5884_101_0	4			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	25						25			25			25		25
S5884	102	0		29	10	S5884_102_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	0		0				0		0	0		0	0		0
S5884	102	0		29	10	S5884_102_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	102	0		29	10	S5884_102_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				40.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	102	0		29	10	S5884_102_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				60.00	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	25						25			25			25		25
S5884	102	0		29	10	S5884_102_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	25						25			25			25		25
S5884	103	0		29	10	S5884_103_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	0		0				0		0	0		0	0		0
S5884	103	0		29	10	S5884_103_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	103	0		29	10	S5884_103_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				40.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	103	0		29	10	S5884_103_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				61.00	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	25						25			25			25		25
S5884	103	0		29	10	S5884_103_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	25						25			25			25		25
S5884	104	0		29	10	S5884_104_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	0		0				0		0	0		0	0		0
S5884	104	0		29	10	S5884_104_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	104	0		29	10	S5884_104_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	104	0		29	10	S5884_104_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	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	25						25			25			25		25
S5884	104	0		29	10	S5884_104_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				39.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	105	0		29	10	S5884_105_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				50.00	36																										36						36					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				37.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	106	0		29	10	S5884_106_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
S5884	107	0		29	10	S5884_107_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	0		0				0		0	0		0	0		0
S5884	107	0		29	10	S5884_107_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	107	0		29	10	S5884_107_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	107	0		29	10	S5884_107_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				49.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
S5884	107	0		29	10	S5884_107_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				42.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	108	0		29	10	S5884_108_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				62.00	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	25						25			25			25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				35.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	109	0		29	10	S5884_109_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				48.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
S5884	110	0		29	10	S5884_110_0	3			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	0		0				0		0	0		0	0		0
S5884	110	0		29	10	S5884_110_0	3			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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	110	0		29	10	S5884_110_0	3			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				41.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	110	0		29	10	S5884_110_0	3			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				63.00	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	25						25			25			25		25
S5884	110	0		29	10	S5884_110_0	3			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	25						25			25			25		25
S5884	111	0		29	10	S5884_111_0	3			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	0		0				0		0	0		0	0		0
S5884	111	0		29	10	S5884_111_0	3			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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	111	0		29	10	S5884_111_0	3			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	111	0		29	10	S5884_111_0	3			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	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	25						25			25			25		25
S5884	111	0		29	10	S5884_111_0	3			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	25						25			25			25		25
S5884	112	0		29	10	S5884_112_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	0		0				0		0	0		0	0		0
S5884	112	0		29	10	S5884_112_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	112	0		29	10	S5884_112_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				42.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	112	0		29	10	S5884_112_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				56.00	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	25						25			25			25		25
S5884	112	0		29	10	S5884_112_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	25						25			25			25		25
S5884	113	0		29	10	S5884_113_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	0		0				0		0	0		0	0		0
S5884	113	0		29	10	S5884_113_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	113	0		29	10	S5884_113_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				40.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	113	0		29	10	S5884_113_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				61.00	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	25						25			25			25		25
S5884	113	0		29	10	S5884_113_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				42.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	114	0		29	10	S5884_114_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				59.00	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	25						25			25			25		25
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	25						25			25			25		25
S5884	115	0		29	10	S5884_115_0	2			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				0.00		0.00				3.00				3.00		0.10				0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00		9.00				3.00		9.00	0.00		0.00	3.00		3.00	25		25				25		25	0		0	25		25
S5884	115	0		29	10	S5884_115_0	2			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				0.00		0.00				4.00				4.00		0.13				0.13	0.00	0.13	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	4.00		12.00				4.00		12.00	0.00		0.00	4.00		4.00	25		25				25		25	0		0	25		25
S5884	115	0		29	10	S5884_115_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				43.00	23		23																								23		23				18		18			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	23		23				23		23	18		18	23		23
S5884	115	0		29	10	S5884_115_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				56.00	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	25						25			25			25		25
S5884	115	0		29	10	S5884_115_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	25						25			25			25		25
S5884	116	0		29	10	S5884_116_0	3			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				0.00		0.00				2.00				2.00		0.07				0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		6.00	0.00		0.00	2.00		2.00	25		25				25		25	0		0	25		25
S5884	116	0		29	10	S5884_116_0	3			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				0.00		0.00				3.00				3.00		0.10				0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00		9.00				3.00		9.00	0.00		0.00	3.00		3.00	25		25				25		25	0		0	25		25
S5884	116	0		29	10	S5884_116_0	3			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				46.00	24		24																								24		24				19		19			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	24		24				24		24	19		19	24		24
S5884	116	0		29	10	S5884_116_0	3			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	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	25						25			25			25		25
S5884	116	0		29	10	S5884_116_0	3			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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	131	0		29	10	S5884_131_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	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	25						25			25			25		25
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	25						25			25			25		25
S5884	132	0		29	10	S5884_132_0	3			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	0		0				0		0	0		0	0		0
S5884	132	0		29	10	S5884_132_0	3			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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	132	0		29	10	S5884_132_0	3			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				37.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	132	0		29	10	S5884_132_0	3			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	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	25						25			25			25		25
S5884	132	0		29	10	S5884_132_0	3			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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				39.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	133	0		29	10	S5884_133_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				59.00	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	25						25			25			25		25
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	25						25			25			25		25
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				0.00		0.00				2.00				2.00		0.07				0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		6.00	0.00		0.00	2.00		2.00	25		25				25		25	0		0	25		25
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				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	134	0		29	10	S5884_134_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				43.00	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	25						25			25			25		25
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	25						25			25			25		25
S5884	135	0		29	10	S5884_135_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	0		0				0		0	0		0	0		0
S5884	135	0		29	10	S5884_135_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	135	0		29	10	S5884_135_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				37.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	135	0		29	10	S5884_135_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
S5884	135	0		29	10	S5884_135_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	25						25			25			25		25
S5884	136	0		29	10	S5884_136_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	0		0				0		0	0		0	0		0
S5884	136	0		29	10	S5884_136_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	136	0		29	10	S5884_136_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				39.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	136	0		29	10	S5884_136_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				58.00	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	25						25			25			25		25
S5884	136	0		29	10	S5884_136_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	137	0		29	10	S5884_137_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				51.00	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	25						25			25			25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	138	0		29	10	S5884_138_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				52.00	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	25						25			25			25		25
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	25						25			25			25		25
S5884	139	0		29	10	S5884_139_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	0		0				0		0	0		0	0		0
S5884	139	0		29	10	S5884_139_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	139	0		29	10	S5884_139_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	139	0		29	10	S5884_139_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				59.00	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	25						25			25			25		25
S5884	139	0		29	10	S5884_139_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				34.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	140	0		29	10	S5884_140_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				49.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
S5884	141	0		29	10	S5884_141_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	0		0				0		0	0		0	0		0
S5884	141	0		29	10	S5884_141_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	141	0		29	10	S5884_141_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				38.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	141	0		29	10	S5884_141_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				49.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
S5884	141	0		29	10	S5884_141_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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				37.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	142	0		29	10	S5884_142_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				51.00	35																										35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
S5884	143	0		29	10	S5884_143_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	0		0				0		0	0		0	0		0
S5884	143	0		29	10	S5884_143_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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	143	0		29	10	S5884_143_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		90				2	2				30		90	30		31				39.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	143	0		29	10	S5884_143_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				46.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
S5884	143	0		29	10	S5884_143_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	25						25			25			25		25
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				0.00		0.00				2.00				2.00		0.07				0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		6.00	0.00		0.00	2.00		2.00	25		25				25		25	0		0	25		25
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				45.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	144	0		29	10	S5884_144_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				54.00	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	25						25			25			25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				37.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	145	0		29	10	S5884_145_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				53.00	34																										34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00						35.00			35.00			35.00		35.00	25						25			25			25		25
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	25						25			25			25		25
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				0.00		0.00				2.00				2.00		0.07				0.07	0.00	0.06	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	2.00		6.00				2.00		6.00	0.00		0.00	2.00		2.00	25		25				25		25	0		0	25		25
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				0.00		0.00				3.00				3.00		0.10				0.10	0.00	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00		9.00				3.00		9.00	0.00		0.00	3.00		3.00	25		25				25		25	0		0	25		25
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				38.00	23		23																								23		23				18		18			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	23		23				23		23	18		18	23		23
S5884	146	0		29	10	S5884_146_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				54.00	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	25						25			25			25		25
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	25						25			25			25		25
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	0		0				0		0	0		0	0		0
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				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
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				39.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	147	0		29	10	S5884_147_0	1			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				57.00	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	25						25			25			25		25
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	25						25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											50.00	50		50				38.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											56.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											55.00	50		50				53.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											54.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											44.00	50		50				39.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											48.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											51.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											46.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											51.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											46.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											48.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											50.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											47.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											53.00	50		50				41.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											46.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											45.00	50		50				36.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											43.00	50		50				36.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											46.00	50		50				39.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											50.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											48.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											49.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											47.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											52.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											53.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											51.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											52.00	50		50				56.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											44.00	50		50				41.00	50		50										50		50				50		50			50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											47.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											60.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											60.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
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	25		25	25		25	25		25	25		25	25		25
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											52.00	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	25		25	25		25	25		25	25		25	25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											35.00	20		20				36.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	181	0		29	10	S5884_181_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											43.00	31						39.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	182	0		29	10	S5884_182_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	25		25	0		0	25		25	0		0	25		25
S5884	182	0		29	10	S5884_182_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	25		25	0		0	25		25	0		0	25		25
S5884	182	0		29	10	S5884_182_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											30.00	18		18				31.00	18		18										18		18				13		13			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	18		18	18		18	18		18	13		13	18		18
S5884	182	0		29	10	S5884_182_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											49.00	31						46.00	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	25			25			25			25			25		25
S5884	182	0		29	10	S5884_182_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	25			25			25			25			25		25
S5884	183	0		29	10	S5884_183_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	25		25	0		0	25		25	0		0	25		25
S5884	183	0		29	10	S5884_183_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	25		25	0		0	25		25	0		0	25		25
S5884	183	0		29	10	S5884_183_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											32.00	19		19				34.00	19		19										19		19				14		14			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	19		19	19		19	19		19	14		14	19		19
S5884	183	0		29	10	S5884_183_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											49.00	32						45.00	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		35.00	25			25			25			25			25		25
S5884	183	0		29	10	S5884_183_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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				31.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	184	0		29	10	S5884_184_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											40.00	33						37.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	185	0		29	10	S5884_185_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											39.00	33						35.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	186	0		29	10	S5884_186_0	2			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											1.00		3.00				0.00		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	0.00		0.00	1.00		3.00	0.00		0.00	0.00		0.00	0		0	0		0	25		25	0		0	0		0
S5884	186	0		29	10	S5884_186_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								1.00		3.00					0.00		0.00											3.00		9.00				0.00		0.00				1.00				1.00			0.03	0.00		0.10	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00	0.00		0.00	3.00		9.00	0.00		0.00	1.00		1.00	25		25	0		0	25		25	0		0	25		25
S5884	186	0		29	10	S5884_186_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											31.00	20		20				31.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	186	0		29	10	S5884_186_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											36.00	32						36.00	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		35.00	25			25			25			25			25		25
S5884	186	0		29	10	S5884_186_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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	187	0		29	10	S5884_187_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											36.00	34						36.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											31.00	19		19				30.00	19		19										19		19				14		14			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	19		19	19		19	19		19	14		14	19		19
S5884	188	0		29	10	S5884_188_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	34						39.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											31.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	189	0		29	10	S5884_189_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											38.00	34						36.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	190	0		29	10	S5884_190_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	25		25	0		0	25		25	0		0	25		25
S5884	190	0		29	10	S5884_190_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	25		25	0		0	25		25	0		0	25		25
S5884	190	0		29	10	S5884_190_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											33.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	190	0		29	10	S5884_190_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											42.00	33						36.00	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	25			25			25			25			25		25
S5884	190	0		29	10	S5884_190_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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				31.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	191	0		29	10	S5884_191_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											35.00	33						34.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											33.00	20		20				34.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	192	0		29	10	S5884_192_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											42.00	33						35.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											33.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	193	0		29	10	S5884_193_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											36.00	34						35.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											33.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	194	0		29	10	S5884_194_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											36.00	34						34.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	195	0		29	10	S5884_195_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								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	25		25	0		0	25		25	0		0	25		25
S5884	195	0		29	10	S5884_195_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								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	25		25	0		0	25		25	0		0	25		25
S5884	195	0		29	10	S5884_195_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											33.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	195	0		29	10	S5884_195_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											38.00	35						36.00	35												35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5884	195	0		29	10	S5884_195_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												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	25			25			25			25			25		25
S5884	196	0		29	10	S5884_196_0	2			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		90	1	2				30		90	30		31								0.00		0.00					0.00		0.00											1.00		3.00				0.00		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	0.00		0.00	1.00		3.00	0.00		0.00	0.00		0.00	0		0	0		0	25		25	0		0	0		0
S5884	196	0		29	10	S5884_196_0	2			Generic	4	11	1	2	2	1		110	01		110	1				30		90	2	2				30		90	30		31								1.00		3.00					0.00		0.00											4.00		12.00				0.00		0.00				1.00				1.00			0.03	0.00		0.13	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00	0.00		0.00	4.00		12.00	0.00		0.00	1.00		1.00	25		25	0		0	25		25	0		0	25		25
S5884	196	0		29	10	S5884_196_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											34.00	20		20				34.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	196	0		29	10	S5884_196_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	35						36.00	35												35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5884	196	0		29	10	S5884_196_0	2			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30								30			30		31												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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											31.00	20		20				30.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	197	0		29	10	S5884_197_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											33.00	34						30.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											31.00	20		20				30.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	198	0		29	10	S5884_198_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											33.00	33						34.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											33.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	199	0		29	10	S5884_199_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											35.00	35						32.00	35												35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	200	0		29	10	S5884_200_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											37.00	35						33.00	35												35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	201	0		29	10	S5884_201_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	25		25	0		0	25		25	0		0	25		25
S5884	201	0		29	10	S5884_201_0	2			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	25		25	0		0	25		25	0		0	25		25
S5884	201	0		29	10	S5884_201_0	2			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		90	2	2				30		90	30		31											34.00	20		20				35.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	201	0		29	10	S5884_201_0	2			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	34						41.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5884	201	0		29	10	S5884_201_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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											37.00	20		20				36.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	202	0		29	10	S5884_202_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											37.00	35						35.00	35												35						35					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				31.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	203	0		29	10	S5884_203_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											31.00	32						32.00	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		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											34.00	20		20				34.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	204	0		29	10	S5884_204_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											35.00	34						32.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											36.00	20		20				36.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	205	0		29	10	S5884_205_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											41.00	30						40.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											38.00	20		20				35.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	206	0		29	10	S5884_206_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											43.00	34						36.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											34.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	207	0		29	10	S5884_207_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											39.00	34						38.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											29.00	18		18				31.00	18		18										18		18				13		13			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	18		18	18		18	18		18	13		13	18		18
S5884	208	0		29	10	S5884_208_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	34						43.00	34												34						34					34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	20		20				32.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	209	0		29	10	S5884_209_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											36.00	33						35.00	33												33						33					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											33.00	20		20				33.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	210	0		29	10	S5884_210_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											30.00	32						30.00	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		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											32.00	18		18				32.00	18		18										18		18				13		13			18			18								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	18		18	18		18	18		18	13		13	18		18
S5884	211	0		29	10	S5884_211_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	32						44.00	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		35.00	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											39.00	20		20				43.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	212	0		29	10	S5884_212_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	30						46.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
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	25		25	0		0	25		25	0		0	25		25
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	25		25	0		0	25		25	0		0	25		25
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											38.00	20		20				38.00	20		20										20		20				15		15			20			20								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00	35.00		105.00	35.00		105.00	35.00		35.00	20		20	20		20	20		20	15		15	20		20
S5884	213	0		29	10	S5884_213_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	33						48.00	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	25			25			25			25			25		25
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	25			25			25			25			25		25
S5884	216	0		29	10	S5884_216_0	2			Preferred Generic	2	11	1	2	1	1	110		01		110	1	30		100				1	2				30		100	30		31	0.00		0.00																									0.00		0.00				0.00		0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	0.00		0.00				0.00		0.00	0.00		0.00	0.00		0.00	0		0				0		0	0		0	0		0
S5884	216	0		29	10	S5884_216_0	2			Generic	2	11	1	2	2	1	110		01		110	1	30		100				2	2				30		100	30		31	1.00		3.00																									1.00		3.00				0.00		0.00				1.00				1.00		0.03				0.03	0.00	0.03	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	1.00		3.00				1.00		3.00	0.00		0.00	1.00		1.00	25		25				25		25	0		0	25		25
S5884	216	0		29	10	S5884_216_0	2			Preferred Brand	2	11	1	1	3	1	110		01		110	1	30		100				2	2				30		100	30		31				45.00	25		25																								25		25				20		20			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	25		25				25		25	20		20	25		25
S5884	216	0		29	10	S5884_216_0	2			Non-Preferred Drug	2	11	1	1	4	1	010		01		010	1	30						2	2				30			30		31				70.00	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	25						25			25			25		25
S5884	216	0		29	10	S5884_216_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	25						25			25			25		25
S5884	217	0		29	10	S5884_217_0	1			Preferred Generic	4	11	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		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	25		25	0		0	25		25	0		0	25		25
S5884	217	0		29	10	S5884_217_0	1			Generic	4	11	3	2	2	1		110	01		110	1				30		100	2	2				30		100	30		31								10.00		30.00					4.00		12.00											10.00		30.00				0.00		0.00				10.00				10.00			0.33	0.13		0.33	0.00	0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	10.00		30.00	4.00		12.00	10.00		30.00	0.00		0.00	10.00		10.00	25		25	25		25	25		25	0		0	25		25
S5884	217	0		29	10	S5884_217_0	1			Preferred Brand	4	11	1	2	3	1		110	01		110	1				30		100	2	2				30		100	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	25		25	25		25	25		25	25		25	25		25
S5884	217	0		29	10	S5884_217_0	1			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				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	25		25	25		25	25		25	25		25	25		25
S5884	217	0		29	10	S5884_217_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	25			25			25			25			25		25
S5884	218	0		29	10	S5884_218_0	1			Preferred Generic	4	11	1	2	1	1		110	01		110	1				30		100	1	2				30		100	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	25		25	0		0	25		25	0		0	25		25
S5884	218	0		29	10	S5884_218_0	1			Generic	4	11	1	2	2	1		110	01		110	1				30		100	2	2				30		100	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	25		25	0		0	25		25	0		0	25		25
S5884	218	0		29	10	S5884_218_0	1			Preferred Brand	4	11	1	1	3	1		110	01		110	1				30		100	2	2				30		100	30		31											31.00	17		17				32.00	17		17										17		17				12		12			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	17		17	17		17	17		17	12		12	17		17
S5884	218	0		29	10	S5884_218_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											62.00	31						36.00	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	25			25			25			25			25		25
S5884	218	0		29	10	S5884_218_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	25			25			25			25			25		25
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	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																														
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	14.00		42.00																			14.00		42.00																14.00				14.00		0.45			0.45			0.45	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S5904	001	0		29	10	S5904_001_0	6			Preferred Brand	3	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				45.15	20		20																		20		20															20			20								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	20		20				20		20				20		20
S5904	001	0		29	10	S5904_001_0	6			Non-Preferred Drug	3	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				63.50	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		35.00	25		25				25		25				25		25
S5904	001	0		29	10	S5904_001_0	6			Specialty Tier	3	11	1	1	5	1	010		01	010		1	31								31						31		31				1206.23	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	25						25						25		25
S5904	001	0		29	10	S5904_001_0	6			Select Care Drugs	3	11	1	2	6	1	110		01	110		1	31		90				1	2	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, Select Care Drugs																														
S5904	002	0		29	10	S5904_002_0	7			Preferred Generic	4	01	1	2	1	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, Select Care Drugs																														
S5904	002	0		29	10	S5904_002_0	7			Generic	4	01	1	2	2	1	110		01	110		1	31		90				1	2	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, Select Care Drugs																														
S5904	002	0		29	10	S5904_002_0	7			Preferred Brand	4	11	1	1	3	1	110		01	110		1	31		90				1	2	31		90				31		31				62.93	18		18																		18		18															18			18								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	18		18				18		18				18		18
S5904	002	0		29	10	S5904_002_0	7			Non-Preferred Drug	4	11	1	1	4	1	110		01	110		1	31		90				1	2	31		90				31		31				44.23	29		29																		29		29															29			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	25		25				25		25				25		25
S5904	002	0		29	10	S5904_002_0	7			Specialty Tier	4	11	1	1	5	1	010		01	010		1	31								31						31		31				1109.09	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	25						25						25		25
S5904	002	0		29	10	S5904_002_0	7			Select Care Drugs	4	11	1	2	6	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, Select Care Drugs																														
S5921	348	0		29	10	S5921_348_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	348	0		29	10	S5921_348_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	348	0		29	10	S5921_348_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	17		17				30.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	348	0		29	10	S5921_348_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	38						52.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	348	0		29	10	S5921_348_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											394.00	25						369.00	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	25			25			25			25			25		25
S5921	349	0		29	10	S5921_349_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	349	0		29	10	S5921_349_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	349	0		29	10	S5921_349_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				33.00	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	17		17	17		17			17			17	17		17
S5921	349	0		29	10	S5921_349_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	39						59.00	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	25			25			25			25			25		25
S5921	349	0		29	10	S5921_349_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											411.00	25						353.00	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	25			25			25			25			25		25
S5921	350	0		29	10	S5921_350_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	350	0		29	10	S5921_350_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	350	0		29	10	S5921_350_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	17		17				31.00	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	17		17	17		17			17			17	17		17
S5921	350	0		29	10	S5921_350_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											46.00	39						53.00	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	25			25			25			25			25		25
S5921	350	0		29	10	S5921_350_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											390.00	25						360.00	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	25			25			25			25			25		25
S5921	351	0		29	10	S5921_351_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	351	0		29	10	S5921_351_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	16		16				28.00	16		16												16						16			16			16								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	16		16	16		16			16			16	16		16
S5921	351	0		29	10	S5921_351_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	44						35.00	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	25			25			25			25			25		25
S5921	351	0		29	10	S5921_351_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											383.00	25						360.00	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	25			25			25			25			25		25
S5921	352	0		29	10	S5921_352_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	352	0		29	10	S5921_352_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	352	0		29	10	S5921_352_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											23.00	17		17				27.00	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	17		17	17		17			17			17	17		17
S5921	352	0		29	10	S5921_352_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											42.00	37						47.00	34												37						34					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	352	0		29	10	S5921_352_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											413.00	25						382.00	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	25			25			25			25			25		25
S5921	353	0		29	10	S5921_353_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	353	0		29	10	S5921_353_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	353	0		29	10	S5921_353_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	18		18				31.00	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	18		18	18		18			18			18	18		18
S5921	353	0		29	10	S5921_353_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											44.00	37						48.00	34												37						34					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	353	0		29	10	S5921_353_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											398.00	25						379.00	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	25			25			25			25			25		25
S5921	354	0		29	10	S5921_354_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	354	0		29	10	S5921_354_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	18		18				35.00	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	18		18	18		18			18			18	18		18
S5921	354	0		29	10	S5921_354_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											46.00	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	25			25			25			25			25		25
S5921	354	0		29	10	S5921_354_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											434.00	25						392.00	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	25			25			25			25			25		25
S5921	355	0		29	10	S5921_355_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	355	0		29	10	S5921_355_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	355	0		29	10	S5921_355_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	18		18				34.00	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	18		18	18		18			18			18	18		18
S5921	355	0		29	10	S5921_355_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											39.00	38						42.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	355	0		29	10	S5921_355_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											429.00	25						369.00	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	25			25			25			25			25		25
S5921	356	0		29	10	S5921_356_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	356	0		29	10	S5921_356_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	356	0		29	10	S5921_356_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	18		18				33.00	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	18		18	18		18			18			18	18		18
S5921	356	0		29	10	S5921_356_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											46.00	38						46.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	356	0		29	10	S5921_356_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											425.00	25						381.00	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	25			25			25			25			25		25
S5921	357	0		29	10	S5921_357_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	357	0		29	10	S5921_357_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	357	0		29	10	S5921_357_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											23.00	17		17				26.00	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	17		17	17		17			17			17	17		17
S5921	357	0		29	10	S5921_357_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											44.00	38						43.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	357	0		29	10	S5921_357_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											381.00	25						368.00	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	25			25			25			25			25		25
S5921	358	0		29	10	S5921_358_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	358	0		29	10	S5921_358_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	358	0		29	10	S5921_358_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				29.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	358	0		29	10	S5921_358_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	36						49.00	33												36						33					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	358	0		29	10	S5921_358_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											387.00	25						372.00	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	25			25			25			25			25		25
S5921	359	0		29	10	S5921_359_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	359	0		29	10	S5921_359_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	359	0		29	10	S5921_359_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	18		18				33.00	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	18		18	18		18			18			18	18		18
S5921	359	0		29	10	S5921_359_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											39.00	35						41.00	32												35						32					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	359	0		29	10	S5921_359_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											441.00	25						356.00	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	25			25			25			25			25		25
S5921	360	0		29	10	S5921_360_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	360	0		29	10	S5921_360_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				30.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	360	0		29	10	S5921_360_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											49.00	45						47.00	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	25			25			25			25			25		25
S5921	360	0		29	10	S5921_360_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											385.00	25						390.00	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	25			25			25			25			25		25
S5921	361	0		29	10	S5921_361_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	361	0		29	10	S5921_361_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											23.00	17		17				27.00	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	17		17	17		17			17			17	17		17
S5921	361	0		29	10	S5921_361_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	36						45.00	33												36						33					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	361	0		29	10	S5921_361_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											438.00	25						390.00	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	25			25			25			25			25		25
S5921	362	0		29	10	S5921_362_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	362	0		29	10	S5921_362_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	362	0		29	10	S5921_362_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											23.00	17		17				28.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	362	0		29	10	S5921_362_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											47.00	42						48.00	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	25			25			25			25			25		25
S5921	362	0		29	10	S5921_362_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											436.00	25						346.00	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	25			25			25			25			25		25
S5921	363	0		29	10	S5921_363_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	363	0		29	10	S5921_363_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	363	0		29	10	S5921_363_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				30.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	363	0		29	10	S5921_363_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	42						46.00	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	25			25			25			25			25		25
S5921	363	0		29	10	S5921_363_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											384.00	25						322.00	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	25			25			25			25			25		25
S5921	364	0		29	10	S5921_364_0	1			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																8.00				8.00			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	364	0		29	10	S5921_364_0	1			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																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	1			Preferred Brand	2	11	1	1	3	1		110	01	100		1				30		90	2	2			90				30		31											25.00	18		18				32.00	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				35.00		35.00	18		18	18		18			18				18		18
S5921	364	0		29	10	S5921_364_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01	010		1				30			2	2	30						30		31											40.00	35						38.00	32						35																	35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
S5921	364	0		29	10	S5921_364_0	1			Specialty Tier	2	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											412.00	25						333.00	25						25																	25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
S5921	365	0		29	10	S5921_365_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	365	0		29	10	S5921_365_0	1			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					6.00		18.00													30.00						18.00				10.00				10.00			0.33	0.20				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	365	0		29	10	S5921_365_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				26.00	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	17		17	17		17			17			17	17		17
S5921	365	0		29	10	S5921_365_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											39.00	40						44.00	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	25			25			25			25			25		25
S5921	365	0		29	10	S5921_365_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											406.00	25						302.00	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	25			25			25			25			25		25
S5921	366	0		29	10	S5921_366_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	366	0		29	10	S5921_366_0	1			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					6.00		18.00													30.00						18.00				10.00				10.00			0.33	0.20				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	366	0		29	10	S5921_366_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											22.00	16		16				27.00	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	16		16	16		16			16			16	16		16
S5921	366	0		29	10	S5921_366_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	43						52.00	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	25			25			25			25			25		25
S5921	366	0		29	10	S5921_366_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											389.00	25						380.00	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	25			25			25			25			25		25
S5921	367	0		29	10	S5921_367_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	367	0		29	10	S5921_367_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	18		18				34.00	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	18		18	18		18			18			18	18		18
S5921	367	0		29	10	S5921_367_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											44.00	41						46.00	38												41						38					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	367	0		29	10	S5921_367_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											411.00	25						370.00	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	25			25			25			25			25		25
S5921	368	0		29	10	S5921_368_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	368	0		29	10	S5921_368_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	17		17				32.00	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	17		17	17		17			17			17	17		17
S5921	368	0		29	10	S5921_368_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											57.00	44						34.00	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	25			25			25			25			25		25
S5921	368	0		29	10	S5921_368_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											400.00	25						373.00	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	25			25			25			25			25		25
S5921	369	0		29	10	S5921_369_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	369	0		29	10	S5921_369_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				31.00	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	17		17	17		17			17			17	17		17
S5921	369	0		29	10	S5921_369_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	41						48.00	38												41						38					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	369	0		29	10	S5921_369_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											460.00	25						375.00	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	25			25			25			25			25		25
S5921	370	0		29	10	S5921_370_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	370	0		29	10	S5921_370_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				31.00	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	17		17	17		17			17			17	17		17
S5921	370	0		29	10	S5921_370_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											52.00	38						47.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	370	0		29	10	S5921_370_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											414.00	25						385.00	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	25			25			25			25			25		25
S5921	371	0		29	10	S5921_371_0	2			Preferred Generic	2	01	1	2	1	1		110	01		100	1				30		90	2	2						90	30		31								8.00		24.00					2.00		6.00													24.00						6.00				8.00				8.00			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	371	0		29	10	S5921_371_0	2			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					6.00		18.00													30.00						18.00				10.00				10.00			0.33	0.20				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	371	0		29	10	S5921_371_0	2			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	16		16				27.00	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	16		16	16		16			16			16	16		16
S5921	371	0		29	10	S5921_371_0	2			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	46						76.00	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	25			25			25			25			25		25
S5921	371	0		29	10	S5921_371_0	2			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											396.00	25						368.00	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	25			25			25			25			25		25
S5921	372	0		29	10	S5921_372_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	372	0		29	10	S5921_372_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	372	0		29	10	S5921_372_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	19		19				36.00	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
S5921	372	0		29	10	S5921_372_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											52.00	36						48.00	33												36						33					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	372	0		29	10	S5921_372_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											439.00	25						385.00	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	25			25			25			25			25		25
S5921	373	0		29	10	S5921_373_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	373	0		29	10	S5921_373_0	1			Generic	2	01	1	2	2	1		110	01		100	1				30		90	2	2						90	30		31								10.00		30.00					6.00		18.00													30.00						18.00				10.00				10.00			0.33	0.20				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	373	0		29	10	S5921_373_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	19		19				34.00	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
S5921	373	0		29	10	S5921_373_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											48.00	37						55.00	34												37						34					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	373	0		29	10	S5921_373_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											466.00	25						336.00	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	25			25			25			25			25		25
S5921	374	0		29	10	S5921_374_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	374	0		29	10	S5921_374_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	374	0		29	10	S5921_374_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				27.00	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	17		17	17		17			17			17	17		17
S5921	374	0		29	10	S5921_374_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	39						55.00	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	25			25			25			25			25		25
S5921	374	0		29	10	S5921_374_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											470.00	25						378.00	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	25			25			25			25			25		25
S5921	375	0		29	10	S5921_375_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	375	0		29	10	S5921_375_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	375	0		29	10	S5921_375_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											24.00	17		17				25.00	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	17		17	17		17			17			17	17		17
S5921	375	0		29	10	S5921_375_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											44.00	38						50.00	35												38						35					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	375	0		29	10	S5921_375_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											421.00	25						395.00	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	25			25			25			25			25		25
S5921	376	0		29	10	S5921_376_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	376	0		29	10	S5921_376_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				32.00	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	17		17	17		17			17			17	17		17
S5921	376	0		29	10	S5921_376_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											63.00	41						40.00	38												41						38					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	376	0		29	10	S5921_376_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											412.00	25						379.00	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	25			25			25			25			25		25
S5921	377	0		29	10	S5921_377_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	377	0		29	10	S5921_377_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	377	0		29	10	S5921_377_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	19		19				36.00	19		19												19						19			19			19								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	19		19	19		19			19			19	19		19
S5921	377	0		29	10	S5921_377_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	36						58.00	33												36						33					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	377	0		29	10	S5921_377_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											449.00	25						413.00	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	25			25			25			25			25		25
S5921	378	0		29	10	S5921_378_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	378	0		29	10	S5921_378_0	1			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	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											25.00	17		17				30.00	17		17												17						17			17			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	17		17	17		17			17			17	17		17
S5921	378	0		29	10	S5921_378_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	39						52.00	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	25			25			25			25			25		25
S5921	378	0		29	10	S5921_378_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											357.00	25						392.00	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	25			25			25			25			25		25
S5921	379	0		29	10	S5921_379_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	379	0		29	10	S5921_379_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	379	0		29	10	S5921_379_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	17		17				33.00	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	17		17	17		17			17			17	17		17
S5921	379	0		29	10	S5921_379_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											52.00	41						63.00	38												41						38					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	379	0		29	10	S5921_379_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											416.00	25						359.00	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	25			25			25			25			25		25
S5921	380	0		29	10	S5921_380_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	380	0		29	10	S5921_380_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	380	0		29	10	S5921_380_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	18		18				29.00	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	18		18	18		18			18			18	18		18
S5921	380	0		29	10	S5921_380_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											50.00	39						47.00	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	25			25			25			25			25		25
S5921	380	0		29	10	S5921_380_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											450.00	25						375.00	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	25			25			25			25			25		25
S5921	381	0		29	10	S5921_381_0	1			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			0.27	0.07				0.26	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	381	0		29	10	S5921_381_0	1			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	0.27				0.32	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	381	0		29	10	S5921_381_0	1			Preferred Brand	2	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	16		16				30.00	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	16		16	16		16			16			16	16		16
S5921	381	0		29	10	S5921_381_0	1			Non-Preferred Drug	2	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											68.00	41						65.00	38												41						38					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	381	0		29	10	S5921_381_0	1			Specialty Tier	2	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											400.00	25						447.00	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	25			25			25			25			25		25
S5921	382	0		29	10	S5921_382_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	382	0		29	10	S5921_382_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	15		15				30.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	382	0		29	10	S5921_382_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	33						69.00	28												33						28					33			33								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	382	0		29	10	S5921_382_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											526.00	31						458.00	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	25			25			25			25			25		25
S5921	383	0		29	10	S5921_383_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	383	0		29	10	S5921_383_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	17		17				33.00	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	17		17	17		17			17			17	17		17
S5921	383	0		29	10	S5921_383_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											63.00	39						63.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	383	0		29	10	S5921_383_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											533.00	31						464.00	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	25			25			25			25			25		25
S5921	384	0		29	10	S5921_384_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	384	0		29	10	S5921_384_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	15		15				29.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	384	0		29	10	S5921_384_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	35						58.00	30												35						30					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	384	0		29	10	S5921_384_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											526.00	31						480.00	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	25			25			25			25			25		25
S5921	385	0		29	10	S5921_385_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	385	0		29	10	S5921_385_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	15		15				30.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	385	0		29	10	S5921_385_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	35						66.00	30												35						30					35			35								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	385	0		29	10	S5921_385_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											509.00	31						477.00	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	25			25			25			25			25		25
S5921	386	0		29	10	S5921_386_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	386	0		29	10	S5921_386_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	15		15				31.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	386	0		29	10	S5921_386_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	38						73.00	33												38						33					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	386	0		29	10	S5921_386_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											521.00	31						446.00	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	25			25			25			25			25		25
S5921	387	0		29	10	S5921_387_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	387	0		29	10	S5921_387_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	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	17		17	17		17			17			17	17		17
S5921	387	0		29	10	S5921_387_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	39						67.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	387	0		29	10	S5921_387_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											514.00	31						462.00	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	25			25			25			25			25		25
S5921	388	0		29	10	S5921_388_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	388	0		29	10	S5921_388_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	16		16				33.00	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	16		16	16		16			16			16	16		16
S5921	388	0		29	10	S5921_388_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	38						76.00	33												38						33					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	388	0		29	10	S5921_388_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											528.00	31						461.00	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	25			25			25			25			25		25
S5921	389	0		29	10	S5921_389_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	389	0		29	10	S5921_389_0	1			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	1			Preferred Brand	4	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	17		17	17		17			17			17	17		17
S5921	389	0		29	10	S5921_389_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											53.00	40						65.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	389	0		29	10	S5921_389_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											482.00	31						463.00	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	25			25			25			25			25		25
S5921	390	0		29	10	S5921_390_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	390	0		29	10	S5921_390_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	17		17				33.00	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	17		17	17		17			17			17	17		17
S5921	390	0		29	10	S5921_390_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	38						64.00	33												38						33					38			38								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	390	0		29	10	S5921_390_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											531.00	31						448.00	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	25			25			25			25			25		25
S5921	391	0		29	10	S5921_391_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	391	0		29	10	S5921_391_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	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	17		17	17		17			17			17	17		17
S5921	391	0		29	10	S5921_391_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											63.00	40						67.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	391	0		29	10	S5921_391_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											508.00	31						465.00	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	25			25			25			25			25		25
S5921	392	0		29	10	S5921_392_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	392	0		29	10	S5921_392_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	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	16		16	16		16			16			16	16		16
S5921	392	0		29	10	S5921_392_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	41						66.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	392	0		29	10	S5921_392_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											554.00	31						463.00	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	25			25			25			25			25		25
S5921	393	0		29	10	S5921_393_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	393	0		29	10	S5921_393_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	17		17				33.00	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	17		17	17		17			17			17	17		17
S5921	393	0		29	10	S5921_393_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	39						61.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	393	0		29	10	S5921_393_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											582.00	31						447.00	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	25			25			25			25			25		25
S5921	394	0		29	10	S5921_394_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	394	0		29	10	S5921_394_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											34.00	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	18		18	18		18			18			18	18		18
S5921	394	0		29	10	S5921_394_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											51.00	37						67.00	32												37						32					37			37								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	394	0		29	10	S5921_394_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											521.00	31						463.00	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	25			25			25			25			25		25
S5921	395	0		29	10	S5921_395_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	395	0		29	10	S5921_395_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	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	17		17	17		17			17			17	17		17
S5921	395	0		29	10	S5921_395_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	41						66.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	395	0		29	10	S5921_395_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											533.00	31						458.00	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	25			25			25			25			25		25
S5921	396	0		29	10	S5921_396_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	396	0		29	10	S5921_396_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	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	18		18	18		18			18			18	18		18
S5921	396	0		29	10	S5921_396_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	39						62.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	396	0		29	10	S5921_396_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											551.00	31						460.00	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	25			25			25			25			25		25
S5921	397	0		29	10	S5921_397_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	397	0		29	10	S5921_397_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	15		15				29.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	397	0		29	10	S5921_397_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	41						62.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	397	0		29	10	S5921_397_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											473.00	31						470.00	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	25			25			25			25			25		25
S5921	398	0		29	10	S5921_398_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	398	0		29	10	S5921_398_0	1			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	1			Preferred Brand	4	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	17		17	17		17			17			17	17		17
S5921	398	0		29	10	S5921_398_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	43						66.00	38												43						38					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	398	0		29	10	S5921_398_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											540.00	31						453.00	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	25			25			25			25			25		25
S5921	399	0		29	10	S5921_399_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	399	0		29	10	S5921_399_0	1			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	1			Preferred Brand	4	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	17		17	17		17			17			17	17		17
S5921	399	0		29	10	S5921_399_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	40						61.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	399	0		29	10	S5921_399_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											544.00	31						456.00	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	25			25			25			25			25		25
S5921	400	0		29	10	S5921_400_0	1			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																13.00				13.00			0.43	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	400	0		29	10	S5921_400_0	1			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																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	1			Preferred Brand	4	11	1	1	3	1		110	01	100		1				30		90	2	2			90				30		31											30.00	16		16				31.00	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				35.00		35.00	16		16	16		16			16				16		16
S5921	400	0		29	10	S5921_400_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01	010		1				30			2	2	30						30		31											41.00	34						50.00	29						34																	34			34								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
S5921	400	0		29	10	S5921_400_0	1			Specialty Tier	4	11	1	1	5	1		010	01	010		1				30			2	2	30						30		31											521.00	31						453.00	31						31																	31			31								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00						35.00		35.00	25			25			25						25		25
S5921	401	0		29	10	S5921_401_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	401	0		29	10	S5921_401_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	16		16				31.00	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	16		16	16		16			16			16	16		16
S5921	401	0		29	10	S5921_401_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											45.00	39						63.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	401	0		29	10	S5921_401_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											538.00	31						457.00	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	25			25			25			25			25		25
S5921	402	0		29	10	S5921_402_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	402	0		29	10	S5921_402_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	15		15				30.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	402	0		29	10	S5921_402_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	41						65.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	402	0		29	10	S5921_402_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											499.00	31						491.00	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	25			25			25			25			25		25
S5921	403	0		29	10	S5921_403_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	403	0		29	10	S5921_403_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	18		18				37.00	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	18		18	18		18			18			18	18		18
S5921	403	0		29	10	S5921_403_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	40						61.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	403	0		29	10	S5921_403_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											544.00	31						459.00	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	25			25			25			25			25		25
S5921	404	0		29	10	S5921_404_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	404	0		29	10	S5921_404_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											31.00	16		16				33.00	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	16		16	16		16			16			16	16		16
S5921	404	0		29	10	S5921_404_0	1			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	25			25			25			25			25		25
S5921	404	0		29	10	S5921_404_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											554.00	31						445.00	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	25			25			25			25			25		25
S5921	405	0		29	10	S5921_405_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	405	0		29	10	S5921_405_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											26.00	15		15				31.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	405	0		29	10	S5921_405_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											68.00	43						67.00	38												43						38					43			43								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	405	0		29	10	S5921_405_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											541.00	31						451.00	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	25			25			25			25			25		25
S5921	406	0		29	10	S5921_406_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	406	0		29	10	S5921_406_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											35.00	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	18		18	18		18			18			18	18		18
S5921	406	0		29	10	S5921_406_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											58.00	39						62.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	406	0		29	10	S5921_406_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											543.00	31						473.00	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	25			25			25			25			25		25
S5921	407	0		29	10	S5921_407_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	407	0		29	10	S5921_407_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											29.00	16		16				31.00	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	16		16	16		16			16			16	16		16
S5921	407	0		29	10	S5921_407_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											55.00	40						67.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	407	0		29	10	S5921_407_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											603.00	31						459.00	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	25			25			25			25			25		25
S5921	408	0		29	10	S5921_408_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	408	0		29	10	S5921_408_0	1			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	1			Preferred Brand	4	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	17		17	17		17			17			17	17		17
S5921	408	0		29	10	S5921_408_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											69.00	42						66.00	37												42						37					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	408	0		29	10	S5921_408_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											542.00	31						465.00	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	25			25			25			25			25		25
S5921	409	0		29	10	S5921_409_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	409	0		29	10	S5921_409_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											33.00	18		18				36.00	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	18		18	18		18			18			18	18		18
S5921	409	0		29	10	S5921_409_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											64.00	40						64.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	409	0		29	10	S5921_409_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											556.00	31						468.00	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	25			25			25			25			25		25
S5921	410	0		29	10	S5921_410_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	410	0		29	10	S5921_410_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											34.00	18		18				37.00	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	18		18	18		18			18			18	18		18
S5921	410	0		29	10	S5921_410_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											60.00	41						64.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	410	0		29	10	S5921_410_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											503.00	31						453.00	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	25			25			25			25			25		25
S5921	411	0		29	10	S5921_411_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	411	0		29	10	S5921_411_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											28.00	16		16				31.00	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	16		16	16		16			16			16	16		16
S5921	411	0		29	10	S5921_411_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											59.00	42						67.00	37												42						37					42			42								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	411	0		29	10	S5921_411_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											526.00	31						450.00	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	25			25			25			25			25		25
S5921	412	0		29	10	S5921_412_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	412	0		29	10	S5921_412_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	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	17		17	17		17			17			17	17		17
S5921	412	0		29	10	S5921_412_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											56.00	41						62.00	36												41						36					41			41								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	412	0		29	10	S5921_412_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											518.00	31						445.00	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	25			25			25			25			25		25
S5921	413	0		29	10	S5921_413_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	413	0		29	10	S5921_413_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											27.00	15		15				29.00	15		15												15						15			15			15								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00		105.00	35.00		105.00			105.00			105.00	35.00		35.00	15		15	15		15			15			15	15		15
S5921	413	0		29	10	S5921_413_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											61.00	36						71.00	31												36						31					36			36								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	413	0		29	10	S5921_413_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											509.00	31						466.00	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	25			25			25			25			25		25
S5921	414	0		29	10	S5921_414_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	414	0		29	10	S5921_414_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											32.00	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	17		17	17		17			17			17	17		17
S5921	414	0		29	10	S5921_414_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											89.00	39						58.00	34												39						34					39			39								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	414	0		29	10	S5921_414_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											508.00	31						449.00	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	25			25			25			25			25		25
S5921	415	0		29	10	S5921_415_0	1			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	0.17				0.42	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier																														
S5921	415	0		29	10	S5921_415_0	1			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	1			Preferred Brand	4	11	1	1	3	1		110	01		100	1				30		90	2	2						90	30		31											30.00	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	18		18	18		18			18			18	18		18
S5921	415	0		29	10	S5921_415_0	1			Non-Preferred Drug	4	11	1	1	4	1		010	01		010	1				30			2	2				30			30		31											64.00	40						70.00	35												40						35					40			40								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00			35.00			35.00			35.00			35.00		35.00	25			25			25			25			25		25
S5921	415	0		29	10	S5921_415_0	1			Specialty Tier	4	11	1	1	5	1		010	01		010	1				30			2	2				30			30		31											528.00	31						482.00	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	25			25			25			25			25		25
S5953	001	0		29	10	S5953_001_0	3			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, Select Care Drugs																														
S5953	001	0		29	10	S5953_001_0	3			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, Select Care Drugs																														
S5953	001	0		29	10	S5953_001_0	3			Preferred Brand	3	10	1	1	3	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											47.04	19	19	19				42.09	17	17	17				17	17	17															19			17								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	19	19	19	17	17	17	17	17	17				19		17
S5953	001	0		29	10	S5953_001_0	3			Non-Preferred Drug	3	11	1	1	4	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31											75.86	50	50	50				75.86	50	50	50				50	50	50															50			50								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty 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	25	25	25	25	25	25	25	25	25				25		25
S5953	001	0		29	10	S5953_001_0	3			Specialty Tier	3	11	1	1	5	1		010	01	010		1				30					30						30		31											1356.04	25						1356.04	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	25			25			25						25		25
S5953	001	0		29	10	S5953_001_0	3			Select Care Drugs	3	11	1	2	6	1		111	01	111		1				30	60	90	2	2	30	60	90				30		31								8.00	16.00	24.00					5.00	10.00	15.00					5.00	10.00	12.50																8.00				5.00			0.27	0.17	0.17			0.16	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier, Select Care Drugs																														
S5993	001	0		29	10	S5993_001_0	5			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	0	0	0				0	0	0	0	0	0	0		0
S5993	001	0		29	10	S5993_001_0	5			Generic	2	01	1	2	2	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31	3.00	6.00	9.00																									3.00	6.00	9.00				1.50	3.00	4.50				3.00				3.00		0.10				0.10	0.05	0.10	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	3.00	6.00	9.00				3.00	6.00	9.00	1.50	3.00	4.50	3.00		3.00	25	25	25				25	25	25	25	25	25	25		25
S5993	001	0		29	10	S5993_001_0	5			Preferred Brand	2	11	1	1	3	1	111		01		111	1	30	60	90				1	2				30	60	90	30		31				23.67	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		35.00	18	18	18				18	18	18	18	18	18	18		18
S5993	001	0		29	10	S5993_001_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				81.26	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		35.00	25	25	25				25	25	25	25	25	25	25		25
S5993	001	0		29	10	S5993_001_0	5			Specialty Tier	2	11	1	1	5	1	010		01		000	1	30														30		31				251.44	25																																					25			25								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
S5993	003	0		29	10	S5993_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	0.00	0.00	0.00																									0.00	0.00	0.00				0.00	0.00	0.00				0.00				0.00		0.00				0.00	0.00	0.00	Preferred Generic, 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	0	0				0	0	0	0	0	0	0		0
S5993	003	0		29	10	S5993_003_0	6			Generic	4	01	1	2	2	1	111		01		111	1	30	60	90				1	1				30	60	90	30		31	6.00	12.00	18.00																									6.00	12.00	18.00				3.00	6.00	9.00				6.00				6.00		0.20				0.20	0.10	0.19	Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	6.00	12.00	18.00				6.00	12.00	18.00	3.00	6.00	9.00	6.00		6.00	25	25	25				25	25	25	25	25	25	25		25
S5993	003	0		29	10	S5993_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				42.56	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	20	20	20				20	20	20	20	20	20	20		20
S5993	003	0		29	10	S5993_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				96.39	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	25	25	25				25	25	25	25	25	25	25		25
S5993	003	0		29	10	S5993_003_0	6			Specialty Tier	4	11	1	1	5	1	010		01		000	1	30														30		31				261.24	30																																					30			30								Preferred Generic, Generic, Preferred Brand, Non-Preferred Drug, Specialty Tier	35.00												35.00		35.00	25												25		25
